Fears as 'no medical record exists of examination' that led to fatal discharge of little girl

A coroner has written to Wes Streeting over the tragedy of little Lila Marsland, who was found dead from meningitis, hours after being sent home from hospital being told she had tonsillitis.
The coroner told Mr Streeting that he is 'concerned' about how 'vital clinical information' could risk 'being lost' in a complicated 'mixture of various analogue and digital systems' in use at Tameside General Hospital.
Alarm around missing medical information include that 'no medical record appears to exist of the examination of Lila which was undertaken by the locum registrar in paediatrics which resulted was discharged from hospital'.
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The coroner also aired fears for the rest of the country's hospitals which 'continue to operate with information being stored and shared in a fragmented and disjointed way'.
Lila Marsland was found unresponsive in bed by her mum, dying from meningitis. But around eight hours earlier, the five-year-old was discharged from a long stint in Tameside Hospital as her mum was told she had tonsillitis.
Following an inquest at the start of June, which examined Lila's care and treatment at Tameside General Hospital, a jury concluded her death was preventable and 'contributed to by neglect'.
Coroner Chris Morris told the Secretary of State for Health and Social Care: 'The court heard evidence that, over the course of almost 10 hours in hospital, Lila's history and details of examinations and assessments undertaken were recorded on a mixture of various analogue and digital systems in operation in different parts of the Trust, leading to a risk of vital clinical information being lost in the system.
'I am concerned that this, and other hospitals elsewhere in the country, continue to operate with information being stored and shared between professionals in a fragmented and disjointed way.'
On December 27, 2023, Lila started getting sick. By the evening, Lila's mum - a district nurse who worked for Tameside and Glossop Integrated Care NHS Foundation Trust - knew it was serious enough to take her daughter to the trust's A&E at Tameside Hospital.
Lila was suffering headaches, a sore throat, a high heart rate, neck pain and limited neck movement, vomiting, lethargy and was unable to pass urine.
Lila was sent from adult A&E to paediatric A&E. Mum Rachel Micherton asked hospital staff if it was meningitis.
A number of nurses were concerned meningitis was a possible cause for Lila's illness but, following tests and a review by an experienced paediatric registrar doctor, decided she was more likely suffering from tonsillitis.
The five-year-old was discharged from Tameside Hospital with antibiotics and a throat spray at around 2am on December 28. Around eight hours later, she was found unresponsive in bed by her mum.
She called 999 and attempted CPR. Paramedics arrived, but Lila was pronounced dead at 9.19am.
Following the inquest last month at Stockport Coroners Court, the Greater Manchester South Area Coroner produced two 'prevention of future deaths' reports. The reports are sent to relevant authorities to attempt to stop further deaths from causes uncovered during an inquest.
Along with his letter to Mr Streeting, the coroner also wrote to the bosses of Tameside and Glossop Integrated Care NHS Foundation Trust raising fears about its lacking implementation of the National Institute for Health and Care Excellence (NICE) guidance around meningitis, and notes missing from Lila's case.
The absent notes include a record of the final review of Lila by a senior paediatric registrar before she was fatefully discharged.
The coroner's prevention report aimed at trust bosses reads: 'I am concerned that no medical record appears to exist of the examination of Lila which was undertaken by the locum registrar in paediatrics which resulted was discharged from hospital.
'The absence of this key piece of evidence serves to limit the ability of the trust to derive all possible learning from Lila's death.'
The coroner also shared fears that crucial childhood sepsis screening tools are 'not yet fully embedded in the minds of those who assess and treat children and young people at the trust'.
Mr Morris, too, aired concerns that an emergency medicine consultant who approved Lila's transfer from adult to paediatric A&E 'provided a statement to this court that they had seen' Lila 'and 'visually assessed [her] at least'.
When called to give evidence in court during the inquest, the consultant admitted this had not happened.
Earlier in the inquest, the hearing was told that in a supplementary written statement to the inquest, Dr Muhammad Farooq said: "In this case, on the request of the staff nurse, I performed a preliminary visual assessment and reviewed the patient's vital signs."
However, speaking in the witness box, he said he now accepted that was 'wrong' and he had not 'eyeballed the patient'.
"Do you accept, in this case, those words are misleading?," Mr Morris said. "It implies you had been to see Lila, or seen her from a distance."
"I accept a mistake," Dr Farooq said. "I very openly and honestly accept the mistake."
"Should you have gone to see Lila?" Mr Morris asked.
"If I would have gone to see Lila, in my final assessment I would have transferred the patient in the same manner, to the paediatric emergency department, to get her seen quickly," he said.
Asked how he knew that, Dr Farooq said: "The department was very busy and there was no space downstairs to see the patient. That was the quickest way to see the patient."
Ms Mincherton has not returned to work since Lila's death and was 'uncertain' about doing so, as she would 'need to promote the trust' that dealt with her child.
More than a year on, an inquest determined Lila died from pneumococcal meningitis streptococcal pneumonia.
The Hyde girl's death from meningitis was 'contributed to by neglect', the jury concluded after an eight-day inquest.
'Had Lila been admitted to hospital and given broad spectrum antibiotics within the first hour of being triaged, this would have prevented Lila's death,' the jury concluded.
The trust has apologised and accepted there were failings.
Ms Mincherton, outside court, said: "I would like to thank the jury for coming to this conclusion, based on the evidence provided - a conclusion I have known for 17 months.
"Hearing the word 'neglect' is something a parent should never have to hear and we are now left with the devastating loss of our daughter for the rest of our lives."
Rachael and scaffolder Darren, 42, said their lives - and that of Lila's 15 year-old sister Ava - had been 'devastated'. They have been left feeling 'empty'.
A spokesperson for Tameside and Glossop Integrated Care NHS Foundation Trust said: "We want to express our sincere condolences to Lila's family for their heartbreaking loss.
"It is clear from the independent investigation that there were missed opportunities in Lila's care. We accept the coroner's findings and apologise unreservedly for this.
As a Trust, we have made and will continue to make improvements to ensure we learn from this case."

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Typical angina had all three; atypical angina had 2 of 3, noncardiac had one, and there was also a group with dyspnea only. There were five groups of patients: 25% no symptoms 10% dyspnea only 6% noncardiac 37% atypical chest pain 22% typical angina Now pause. The authors had total plaque volume and FFR-CT on each of these patients. Then they just did correlations. And they found, with these correlations: Only typical angina had a positive correlation with plaque atheroma. Typical angina also correlated strongly with negative values of FFR-CT. The authors also noted, surprisingly, that atypical chest pain, noncardiac chest pain, and dyspnea each correlated with higher FFR-CT, greater than 0.8 suggestive of normal flow. The authors and imaging proponents seem excited about this. In a Medscape news article, one of the authors says: 'Even having no symptoms was not a reliable indicator of cardiovascular health in these patients. 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In other words, symptoms are a very unreliable marker of CAD. Now we have a study that uses have artificial intelligence (AI), CT, FFR, and multivariable regression to confirm something that's as old as the hills. I don't agree with Dr Budoff that cardiologists rely heavily on symptoms. At least not in many places in the US. The main requirement for a stress test in the US is insurance coverage and the main requirement for a cath is a wrist. We don't rely on symptoms. We rely on imaging and angiography. I have this saying that I don't say too much anymore but think often: If every stress imaging machine broke for a month, heart disease outcomes would not change. I wonder whether this also applies to CTA imaging and surely to FFR-CT. A colleague tells me that FFR-CT adds $1500 to basic CTA. I find that shocking. Now I want to go to the advance registry paper in 2018. The main value in this research letter was a kick in the butt to go back to the original evidence for this FFR-CT business, the publication of the ADVANCE registry in the European Heart Journal in 2018. First author Fairbairn. This will be a trigger warning because this is one of those things you can't unsee or unhear. ADVANCE registry included about 5000 patients with symptoms concerning for CAD and atherosclerosis on CCTA. The authors recorded the basic info, symptoms, CCTA and FFR-CT findings were recorded along with treatment plans. They also had 90-day outcomes. For each enrolled patient, a clinical management review committee used data from coronary CTA to determine the management plan using the following criteria: (a) optimal medical therapy, (b) percutaneous coronary intervention (PCI), (c) coronary artery bypass graft surgery (CABG), or (d) more information required. The primary endpoint of the registry is the reclassification rate between the management plan based on coronary CTA alone vs CTA plus FFR-CT. Two teams came up with the original plan based only on CTA. A site team and a blinded core team from Duke. The primary endpoint was the reclassification of the treatment plan from the CT-FFR results. The primary results were that it changed management in about two-thirds of the cases. It was hard for me to see a pattern in the reclassification. The authors tell us later that the majority of subjects were safely deferred to medical management alone, and only a minority required 'further testing.' A second finding was that rate of no significant disease at angiography was significantly lower in patients who had a positive FFR < 0.8 (about 15%) vs > 0.8 (44%). Odds ratio for no significant disease was 0.19 for a positive FFR (that is < 0.8) A third finding was that 19 MACE events happened in the 90 days after the study, 10 of them were death, and all happened in the FFR < 0.8 category — 19 vs 0. The authors concluded that FFR-CT was great. It guided management, helped predict no disease, and even had a strong association with MACE events. They noted this: 'FFR-CT led to a recommendation of invasive coronary angiography (ICA) in only 40% of subjects in a cohort with an anatomic obstructive disease rate of 72%, and subjects referred for ICA downstream were significantly more likely to have obstructive disease at ICA if they had a positive FFR-CT.' And this: 'Importantly, a negative FFR-CT was associated with an excellent short-term prognosis, as none of the 1600 subjects with negative FFR-CT experienced death, MI, or unplanned hospitalization for ACS and urgent revascularization.' A colleague in imaging advises me that this was one of the major studies cited to establish FFR-CT. My gosh, this is terrible. What a mess. First of all, the study was sponsored by HeartFlow. It was a late-breaker at ESC in 2018. I must have had jet lag because I missed it. Much of my criticism follows a Twitter thread from my friend Venk Murthy at University of Michigan. A primary endpoint in change in management in a voluntary registry sponsored by the company is about as weak an endpoint as you can get. Why isn't this a measurement of clinical psychology? What if you chose, say, in a non-industry-funded study, a doctor team skeptical of FFR-CT. I bet few would be swayed by the CT-FFR results. Another problem was that most of the FFR-CT values were abnormal in the left anterior descending artery (LAD) and were between 0.7-0.85. We know this from the IQR values. But now I will cite a study from Christopher Cook in Darrell Francis' group published in JAMA Cardiology 2017. What this London group found is that when doing a systematic review of all studies measuring the diagnostic accuracy of FFR-CT, they found that values just under the cutoff of 0.8 (that is, between 0.7 and 0.8) had the lowest accuracy — only 46% accurate. Pause there. That's like a coin flip. Cook et al report that if you want accuracy from FFR-CT, say 82% overall accuracy threshold, you needed values lower than 0.63 or above 0.83. And if you wanted more stringent 95% and 98% diagnostic accuracy thresholds from FFR-CT, you needed values lower than 0.53 or above 0.93, and lower than 0.47 or above 0.99, respectively. A third issue is that most of the patients (77%) were nontypical angina — either atypical or non-cardiac pain. But we know from the Manesh Patel seminal NEJM paper from 2010 that when patients with atypical symptoms go to cath, the chance of obstructive disease is low — regardless of the results of stress testing. In fact, a positive stress test only changed the likelihood of having CAD from 35% to 41%; hence, my stance that if every stress imaging machine broke, CV outcomes would hardly change. The point in citing this seminal paper is that most patients in the ADVANCE registry study — the 77% with atypical symptoms — should not have had a change in management. A fourth issue is that the MACE events are 100% noise — 19 vs 0. And 10 deaths in the first 90 days. I can't even believe they mentioned MACE events. The CI for the odds ratio goes from 1.2 to 326. The P-value, however, was calculated to be significant at .039, which is crazy. So, in sum, this is one of the weakest, late-breaking, practicing-changing trials I have seen. It's a psychology experiment and we have no idea a) which treatment strategy was best, and b) what meaning is there in changing a treatment strategy without knowing which one is correct. If we wanted to know about FFR-CT, it's simple: you randomize people to care with the HeartFlow FFR-CT vs those without. Then you measure outcomes — MI, CV deaths, even urgent revascularization. But this was not done. Instead, FDA approves the HeartFlow, proponents and key opinion leaders speak highly of it, these studies are not highly criticized, and CT scans get $1500 added to them. HeartFlow was approved de novo in 2014 but received a 2019 clearance for 'virtual modeling.' When I asked my AI friend Claude to explain the difference between the two designations — 2014 and 2019 — one of the 'significant' points was a business model expansion wherein the original FFR-CT was a one-time diagnostic test, but the 'planner (the virtual modeling) creates additional revenue opportunities for each patient who needs intervention.' And then this: the 2019 decision Expands HeartFlow's market from diagnosis into treatment planning. 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To me, this was quite lax regulation. First, there should have been a trial with a sham procedure. Quality-of-life metrics are meaningless when one group gets a procedure and the other group gets bland white tablets. Second, there should have been more patients in the trial. And third, the approval should have been contingent on a required database, such as that with TAVR. This report is really scary given the number of deaths. In fact, mortality from tricuspid valve surgery is the main reason transcatheter techniques were designed. In the transcript, I highlighted in orange font the number of deaths. I counted 14 deaths and 5 cases of ventricular tachycardia/cardiac arrest. Proponents may cite the learning curve, but I doubt it because I read that the company did a slow rollout where centers who were part of the trial were first. And you wonder why I am a medical conservative and slow adopter.