An inquest into the death of a 14-month-old girl has found that late recognition and treatment of sepsis contributed to her death. Jim Duffy appeared for the family of Mia Clarke, instructed by Samantha Critchley of Fieldfisher.

Mia died in the early hours of 30 January 2019. Her father had called the NHS 111 service at 18.47 the night before and spoken with a call handler. One of the first questions he was asked was whether Mia was “limp or floppy”. He responded “yes, she is pretty, pretty floppy.” 

The North West Ambulance Service NHS Trust accepted that this answer ought to have resulted in a Category 2 ambulance being sent without further questions being asked. Instead, the call handler moved on to ask whether Mia was “limp and floppy like a ragdolladding her own further explanation, “so totally lifeless”, to which Mia’s father responded “no, no I wouldn’t say totally lifeless.” The call continued and the disposition reached was that Mia was to have contact with a primary care clinician within an hour.

A nurse called back at 19.09 and decided that Mia should see a doctor within an hour. She was seen by a GP at 20.48, who called an ambulance.

Mia arrived at hospital at 21.41. She was in septic shock. The court heard evidence as to the importance of prompt fluid resuscitation and antibiotic treatment and early involvement of specialist, critical care support in cases of severe sepsis. In Mia’s case, venous access was not established until at least 23.00. Her lactate levels continued to rise. As the night drew on, discussions took place about Mia’s potential transfer to the paediatric intensive care unit at Alder Hey Children’s Hospital, but no transfer took place.

Mia was intubated at 03.50 shortly after she had suffered a cardiac arrest. She died a short time later.

HM Senior Coroner for Cheshire, Jacqueline Devonish, found that there was a delay in escalating Mia’s care to a paediatric specialist and that, while Mia died from natural causes, her death was contributed to by the late recognition and treatment of sepsis following the NHS 111 call.