29 November 2021

Before HM Coroner Andrew Cox
Cornwall Coroner’s Court
Remote or Epiphany House, Truro

29 November 2021– 10 December 2021

The inquest into the death of six-year-old girl with autism, Coco Rose Bradford from Cornwall, will opened on Monday 29 November. Coco was taken to hospital and died unexpectedly in July 2017, leaving serious questions about the standard of care she received.

An independent investigation was conducted by FacereMelius in 2018 which outlines their criticisms of Coco’s care and several missed opportunities to save her life. The inquest will examine these issues and the cause of her death.

On 25 July 2017, Coco was taken to the local A&E at Royal Cornwall Hospital Trust (RCHT) after being sick and experiencing diarrhoea and other symptoms. She was sent home with a diagnosis of gastroenteritis after Emergency Department staff concluded that she could be given fluids and recover there. There are issues around the failure to recognise Coco was at risk, particularly of dehydration.

She returned the next day and was admitted to the paediatric ward at RCHT, where her condition significantly deteriorated. She developed haemolytic uraemic syndrome (HUS, which involves damage to blood vessels that can lead to life-threatening kidney failure). There were persistent problems with record keeping and reviews of observations and test results that prevented consideration of an accurate picture of Coco’s condition.

Coco had autism and her family believe this impacted upon how her care was handled and how important observations were taken (or not taken). The inquest will hear how the Learning Disability and Autism team was not called to assist nursing and clinical staff.

The inquest will also hear expert evidence, ordered by the Coroner, on questions including: whether Coco’s fluid management regime, essential to the treatment of HUS, was adequate; whether Coco was displayed clinical signs of shock throughout her admission which should have led to different management; and, whether she should have been treated with antibiotics for signs of sepsis.

Coco became extremely unwell overnight from 27 to 28 July. On 28 July she was transferred to Bristol Royal Hospital for Children where she was treated on paediatric ICU. On 31 July 2017 she sadly died.


For further information, interview requests and to note your interest, please contact Lucy McKay on 020 7263 1111 or [email protected]

Coco’s family are represented by Charlotte Tracy of Barcan+Kirby Solicitors and Lorna Skinner QC of Matrix Chambers. The family are supported by INQUEST caseworker, Nancy Kelehar.