Parents warning after young Croydon girl's meningitis death

The parents of 11-year-old Annalise are calling for lessons to be learned after an NHS report concluded that neglect contributed to her death, with 11 mistakes made in her care.

Tracey Shephard and David Luffingham took their only child 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.

She was admitted at around 10am on February 11 last year, but hospital staff failed to refer her to a specialist paediatric team where she would've received the antibiotics she desperately needed within an hour.

Annie with parents Tracey and David.

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

Annie was a pupil at Royal Russel School in Croydon, and was academically gifted and incredibly sporty, playing football since three years of age and captaining her school team.

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.

Annalise, aged 11.

The Trust has already admitted liability for Annie’s death, and the couple have spoken out about the dangers of meningitis and the importance of early detection and treatment.

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.

Annie was incredibly sporty and academically gifted.

“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.”

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.

An inquest ruled that neglect contributed to her death.

“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.

Coroner Sonia Hayes recorded a narrative conclusion that Annie died of natural causes contributed to by neglect, adding that there were multiple issues in Annie’s care and it was not just one area or department where care issues arose.

Dami Oloyede, the legal expert at Irwin Mitchell representing Tracey and David, said after the inquest: “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."

The inquest heard staff incorrectly completed a screening tool to asses 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.

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 Croydon 11-year-old, 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. She suffered a cardiac arrest at around 5:30pm.

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.

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.