Coroner concludes 'lamentable' care behind 19-year-old Mia's death at Frimley Park Hospital
Following inquest at Surrey Coroner's Court, Assistant Coroner Dr Karen Henderson concluded last week that Mia Ginever died from a delayed treatment of sepsis and meningitis contributed to by neglect (the legal term describing gross failures to provide basic standards of care).
The Coroner described numerous mistakes, including failing to institute the Sepsis 6 protocol at triage, failing to provide antibiotics until more than eight hours after Mia arrived at the hospital, a complete absence of nursing care and failures in the registrar's review which only occurred five hours after arrival. She described the care as 'lamentable' and held that the failings led to Mia's death.
It has taken a long time for an inquiry to take place since previously the medical examiner at Frimley Park Hospital did not believe there was cause for concern necessitating the Coroner's involvement, despite Mia having been a previously healthy 19-year-old who had been in their care for three days before her death.
It was only once the family learnt more about Mia's condition of meningitis, with the support of the Meningitis Research Foundation, that they realised something had gone terribly wrong and decided to complain about Mia's care which kicked off a serious investigation by the hospital trust.
Following an initial presentation at A&E when she was sent home, Mia's condition deteriorated during the afternoon and evening, with her requiring maximum amounts of painkiller. She noticed a rash – small red spots on her torso. Her mother did the glass test and found it was non-blanching (a classic sign of meningitis). She rang A&E and was told to return to Frimley Park.
They hurried back to A&E and she needed the support of a wheelchair to transfer into the hospital. This is where the catalogue of failings began. It was about 9pm on 6 March 2022 and, despite having plenty of signs suggestive of infection/meningitis (severe headache, vomiting, fever, rash, neck pain) and being assessed as at serious risk of deterioration with a National Early Warning (NEWS) Score of 5, which should have triggered the sepsis pathway, she was left in a corridor to wait and wait to see a doctor with little more than painkillers and fluids.
Her mother went repeatedly to ask when she would be seen and after three hours, she was moved from the corridor to a cubicle. Yet a further two hours passed with no observations being undertaken by any nurse until eventually after five hours, a doctor attended. He did not equip himself with a full picture of her history, did not order any investigations such as blood tests but said like the ED Consultant who had seen her earlier, this is a viral condition. His plan was for fluids, pain medication and discharge. Her mother even asked if she could not have antibiotics as they would not hurt and her request was turned down.
When she was due to be discharged, Mia said her headache was so bad she couldn't leave. She was vomiting constantly. She again sought further assistance and the doctor returned and finally recognised that Mia was seriously ill. He contacted the Medical Team and as Mia now had signs of photophobia and neck stiffness the decision was made to prescribe antibiotics for suspected meningitis.
Further investigations followed but it was too late. Mia suffered a seizure, had to be intubated and put on a ventilator and following a lumbar puncture suffered brain herniation and was certified brain dead at 14.37 on 9 March. Her parents were by her bedside witnessing their daughter's horrendous descent into death.
Mia died of meningococcus serogroup B (Neisseria Meningitis). The Coroner concluded that had she been treated with antibiotics at triage or at the time of the medical review at 02.10 hours this would have prevented her death. As a consequence, Mia died from natural causes contributed to by neglect by Frimley Park Hospital.
Mia's family and friends have raised £90,000 for the Meningitis Research Foundation and are keen to raise awareness of meningitis and that there is a vaccine that would have prevented Mia's death had she received it.
The charity said:
'Today, MenB is the most common cause of meningococcal meningitis circulating in the UK. While not widespread, we monitor cases and have seen a rise amongst teenagers and young adults following the pandemic.
However, there is a routinely available vaccine that protects against other causes of meningococcal meningitis (MenACWY) and we continuously highlight the importance of teenagers taking this up, alongside campaigning for strong public knowledge of the signs and symptoms of meningitis.'
Deborah Nadel acted for the family with Marcus Coates-Walker, barrister at 1 Crown Office Row. She described the circumstances of Mia's death as devastating for the family knowing that their daughter should not have died but for the hospital's failings in care.
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