Parents And Medical Negligence Lawyers Call For Lessons To Be Learned

The parents of an 11-year-old girl who died from meningitis are calling for lessons to be learned after an inquest heard she was in hospital for nearly seven hours before being given antibiotics.     

Tracey Shephard and David Luffingham took their only child Annalise to Croydon University Hospital’s children’s A&E after becoming concerned she had been suffering with a headache and eye pain for a week as well as dizziness and vomiting, confusion and a high temperature.  

The inquest heard staff incorrectly completed a screening tool to assess Annalise, known as Annie, for sepsis – a condition which sees the body attack itself in response to an infection. As such, a specialist sepsis protocol was not instigated resulting in Annie not receiving appropriate treatment. 

Inquest told of delays in administering antibiotics to treat meningitis

After an initial review, Annie, from Addiscombe, Croydon, was referred to A&E’s medical team. However, if the tests had been completed correctly she should have been referred to a specialist paediatric team and should have started receiving intravenous antibiotics within an hour, the inquest heard. 

It also transpired during the course of the inquest that a medical entry concerning Annie’s care was amended months after the event by the consultant in charge of her treatment when the matter was being investigated by the Trust.

The Royal Russell school pupil, who also had an increased respiratory rate, was not reviewed by a paediatric consultant until three hours after arriving in hospital. 

Following further examinations Annie was given ibuprofen and paracetamol. Following a further review intravenous antibiotics were prescribed and administered six-and-a-half hours after Annie arrived at hospital. The inquest heard that staff also failed to note and act upon Annie’s deterioration during this time. 

Just over an hour later Annie suffered a cardiac arrest. She was resuscitated and transferred to another hospital. Annie died the following day.  

Medical negligence lawyers investigate Annie Luffingham's meningitis death 

Following her death Tracey and David, aged 49 and 54 respectively, instructed expert medical negligence lawyers at Irwin Mitchell to help investigate Annie’s care under Croydon Health Services NHS Trust, which runs Croydon University Hospital, and support them through the inquest process.

The Trust has already admitted liability for Annie’s death.

The couple have now joined their legal team at Irwin Mitchell in warning of the dangers of meningitis and the importance of early detection and treatment. 

It comes after coroner Sonia Hayes recorded a narrative conclusion that Annie died of natural causes contributed to by neglect. 

She added there were multiple issues in Annie’s care and it was not just one area or department where care issues arose.

Expert Opinion

“This is a truly tragic case and understandably Tracey and David have been left absolutely devastated by the death of their bright and promising daughter.

“For more than a year the family have had a number of concerns about Annie’s care, with the inquest and the Trust’s own internal investigation report also now identifying a number of worrying areas.

“Sadly through our work we often see the devastating consequences that families can be left to face because of delayed recognition and treatment of meningitis.

“While nothing can make up for the hurt and pain Annie’s family continue to live with, it’s vital that lessons are now learned to improve patient safety so others don’t have to suffer like Tracey and David.

“Awareness of the signs as well as early detection and treatment are key to beating meningitis.” Dami Oloyede - Associate Solicitor

Report finds 11 problems in Annie's care at Croydon hospital

Annie, who was previously fit and healthy, arrived at children’s A&E at Croydon University Hospital at about 10am on February 11 last year. During an initial assessment, tests for sepsis were completed.

Shortly afterwards she was transferred to a team within the main A&E department instead of to a specialist paediatrics team. Annie, who aspired to be a vet, was then transferred to the paediatrics team at around 12.45pm. 

Following more tests Annie was given ibuprofen and paracetamol. At 4pm a consultant prescribed antibiotics which were administered around half an hour later. 

Annie suffered a cardiac arrest at around 5.50pm. 

The Root Cause Analysis Report found 11 problems in Annie’s care, including that sepsis screening was not completed correctly, staff failed to recognise Annie’s respiratory rate was raised, sepsis was not considered as a diagnosis and there was a delay in starting intravenous antibiotics. 

Report says staff should undergo sepsis and meningitis training to improve care 

The report made 17 recommendations to improve care including staff undergo training, including for managing sepsis and meningitis, and intravenous antibiotics should be given within an hour where there is suspicion of sepsis or bacterial meningitis. 

All patients notes should also be on an electronic system and not on paper, and staff need to improve written and verbal communication. 

Parents' tribute to wonderful and beautiful daughter

Tracey said: “Annie was the most wonderful, beautiful and inquisitive daughter we could have ever wished for. She loved horse riding and playing football and was academically gifted. She had been studying for her 11-plus and always wanted to be the best person she could. 

“That she will not grow up to fulfil her potential or celebrate life’s milestones such as passing her exams or starting her first job is something that I don’t think our family will ever get over. 

“We didn’t want to take any chances with Annie’s health and we thought that by taking her to hospital she would be in the best hands possible. It’s difficult not to think that when she needed help the most she was let down. 

“Despite what happened to Annie, it’s vital people are aware of the signs and symptoms of meningitis and continue to seek medical help as soon as possible. It could make all the difference to their family.”

Annie Luffingham's family issue meningitis warning

David added: “It’s almost impossible to find the words to describe the hurt and pain we continue to feel over Annie’s death and particularly the way in which we lost her. 

“However, we try and take some comfort from the kind messages of support and fundraising that has taken place in Annie’s memory. It shows how much others also adored her and can’t thank people enough for their words.   

“By sharing our story we just hope to save lives in the future as people become more aware of the symptoms and of the impact this horrible disease can have.  

“If we can help save at least one life, then Annie’s death may not have been totally in vain.”

Annie was member of the Pony Club at Park Lane Stables in Teddington. Following Annie’s death, the stables and her school organised fundraising events in her memory in aid of Meningitis Now. She had played football since three years of age and captained her school team.

Find out more about our expertise in supporting families affected by infections including meningitis at out dedicated medical negligence section. Alternatively to speak to an expert contact us or call 0370 1500 100.

For more information about meningitis, symptoms and support available visit www.meningitisnow.org