An inquest into the death of a six-year-old girl has concluded an NHS hospital trust made a number of failures in her care before she died.
However, a coroner found there was no evidence that suggested the trust had directly caused or contributed to the death of Maya Siek in December 2022.
Maya was given antibiotics for suspected tonsillitis and sent home from the Queen Elizabeth the Queen Mother hospital in Margate, Kent, two days before she died of heart failure after contracting sepsis.
A series of failures “could have been done differently” by East Kent hospitals university NHS foundation trust, which runs the hospital, the coroner Catherine Wood ruled. She added that she was unsure if any earlier treatment by the trust “could or would have made a difference”.
The failures of the trust included a failure to keep Maya in hospital on the night of 19 December and to inform all members of the team who were treating her about her diagnosis of sepsis when she returned the following day.
Maya had a persistently high heart rate throughout her time in hospital but the trust failed to adequately monitor her vital signs and to contact South Thames Retrieval Service, an intensive care service that transports critically ill children from local hospitals to intensive care units, for support.
Staff also failed to discuss sepsis guidelines with Maya’s parents, Magda Wisniewska and Rajratan Bande.
“There were a number of failures at the trust in relation to Maya’s management,” Wood told the inquest at Oakwood House in Maidstone. “Generally, her condition didn’t appear to have been escalated as it should have been.”
The inquest heard that Maya was a “well looked-after little girl” who had a “lust for life”, before she collapsed and was taken to the A&E department of the hospital by Wisniewska on 19 December 2022.
Doctors determined she had possible tonsillitis and discharged her with some antibiotics, but she collapsed again on her way out of the hospital. After further ECG and blood tests were taken, she was sent home, with advice to come back if her condition deteriorated, the inquest heard.
This decision to discharge Maya was “inappropriate”, Wood said. Brought back in the next day after she had “gone downhill” overnight, Maya was diagnosed with sepsis. Tests also showed influenza.
The inquest heard that nurses failed to document any real admission notes on 20 December about the diagnosis, although Wood ruled these were “non-causative failings”.
Maya suffered from other “chronic conditions”, such as problems with a fatty liver related to obesity and a thickened heart wall. She was given a dose of high-strength sodium chloride at about 2am on 21 December but, after plans made for blood scans were not carried out that morning, Maya went into cardiac arrest.
Despite resuscitation efforts, she died that day.
The coroner accepted the cause of death as heart failure (acute myocardial necrosis), alongside the presence of Maya’s other chronic conditions and influenza.
Wood said that “despite the plethora of evidence that we’ve heard, we still don’t really have the full answers”, and added she was unsure if any earlier treatment by the trust “could or would have made a difference”.
In a statement given after the hearing, Wisniewska said she had been “completely let down” by the hospital she had trusted to take care of Maya. She said: “The trust did not fully appreciate what was wrong with her and there were errors in treatment which meant it was incomplete.
“Our life has been ruined and our family will never be the same without her.”
Dr Des Holden, the chief medical officer for East Kent hospitals, said the trust fully accepted the findings, adding: “We are truly sorry for the devastating loss of Maya and we apologise unreservedly to Maya’s family for the mistakes we made in her care.
“We undertook a thorough investigation, facilitated by an experienced independent paediatrician … and we have made changes to our children’s service as a result.”
