14 January 2022

Before HM Coroner Andrew Cox
Cornwall Coroner’s Court

29 November 2021 – 14 January 2022

Coco Rose Bradford, a six-year-old girl with autism, was taken to hospital in Cornwall and died unexpectedly on 31 July 2017. Today, the inquest has concluded. HM Senior Coroner Andrew Cox’s found it was a death by natural causes, a finding the family continues to dispute. The accompanying narrative conclusion paints a picture of multiple failings during Coco’s care at the Royal Cornwall Hospital in Treliske.

Prior to this inquest, an independent investigation was conducted by Facere Melius in 2018, which outlines their criticisms of Coco’s care and several missed opportunities to save her life. The family felt without this there might never have been an inquest.

Coco’s family describe her as a beautiful girl that taught them patience, humility, tolerance and how to find humour in the face of adversity. She would make everyone listen to Justin Bieber and Little Mix and loved all of the characters in Toy Story, Beauty and the Beast, Finding Nemo and Paw Patrol.

On 25 July 2017, Coco was taken to the local A&E at Royal Cornwall Hospitals NHS Trust (RCHT) after being sick and experiencing diarrhoea and other symptoms. Importantly, her parents had witnessed blood in her nappies. The inquest heard that the registrar who saw Coco that day did not consider that she was dehydrated and found no evidence of blood in her stools.

Coco was sent home with a diagnosis of gastroenteritis after Emergency Department staff concluded that she could be given fluids and recover there. A paediatric expert gave evidence that the decision not to admit Coco on this day amounted to a failure in basic care.

Coco’s parents brought her back to hospital the next day. The inquest heard evidence that when she was seen in A&E she was thought to be dehydrated and confused. A handover took place and a consultant paediatrician, Dr Williams (who was responsible for paediatric patients at the time but did not see Coco) gave evidence that he was not informed of Coco’s confusion. He said this was a concern and may have changed his mind about whether he would have gone to assess Coco.

Coco was admitted to the paediatric ward at RCHT. The inquest heard evidence from multiple witnesses, including an expert paediatrician, that Coco should have been weighed once she reached the paediatric department to assist with managing her fluid balance, a key part of her treatment. Various witnesses gave evidence on the calculation of Coco’s fluid balance, which needed to cover not only her “normal” fluids for the day but replacement fluids for dehydration, as well as any fluids needed to treat shock.

Evidence was given that clinicians had departed from national guidance on fluid management, but several witnesses argued this was appropriate in the circumstances when being cautious about fluid overload and the risk of haemolytic uraemic syndrome (HUS - see below). Dr Goyal, Coco’s on-call consultant on the night of 27 July, conceded that it was not acceptable to rely on fluid calculations done by the day team and it was her responsibility to know and understand the fluid management plan. She probably would have prescribed more fluid had this been checked.

The inquest also heard evidence that several members of staff did not take a blood pressure reading from Coco, which was an important physiological marker of her condition. The Learning Disability and Autism team were not contacted, and may have been able to assist with this.

The inquest heard from Coco’s named consultant, Dr Collinson, that Coco did not have a consultant review from the point of her admission until 10:43am on 27 July. This was some 14-15 hours after she was admitted to the ward, and longer still since her presentation to A&E. Further, Dr Collinson said when he did see Coco, he made mistakes. He accepted that he missed things and got things wrong. He did not recall looking at her observation charts, and believed he did not do this. This meant he was not aware of significant problems like sustained raised heart rate, which would have been very concerning. He did not identify the severity of Coco’s illness and, had he done so, the management plan would have been very different. He apologised to the family.

During her time on the paediatric ward Coco’s condition significantly deteriorated. She developed haemolytic uraemic syndrome (HUS), which involves damage to blood vessels that can lead to life-threatening kidney failure. There had been a concern about HUS throughout Coco’s admission. It was highly suspected by 11pm on 27 July, and confirmed by a blood film at 1am on 28 July. Overnight from 27 to 28 July RCHT was involved in 3 phone calls to the tertiary hospital at Bristol to ask for advice on Coco, particularly on whether to administer antibiotics and whether there was a need to transfer Coco to Bristol. The inquest heard evidence that the accounts of these phone calls differed and that they should have been conducted at consultant level to try to speed an answer to crucial questions.

The question of whether to give antibiotics was discussed at length at inquest. There was said to be some evidence that administering antibiotics could precipitate HUS (essentially bring it on sooner). Coco’s clinical picture and blood results made it clear she was suffering from some sort of massive inflammatory response, but it was not obvious whether this was HUS, or HUS with sepsis. An expert witness in paediatric medicine, Dr Nelly Ninis, felt that antibiotics were mandated by 11pm on 27 July when the HUS diagnosis was established as it was possible Coco’s inflammatory markers were due to sepsis. Other witnesses were more circumspect. It seemed widely agreed that considering the use of antibiotics in HUS necessitated caution.

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.

Coco’s mother, Rachel Bradford, told the inquest how she watched her daughter die in front of her and how the hospital dismissed the family’s concerns even though Coco was in glaringly obvious pain. Rachel gave evidence that Coco’s autism played a role in how she was treated by medical staff and that the professionals wrongly viewed her as being uncooperative and non-compliant.

In his conclusions, HM Senior Coroner Andrew Cox found that:

• The decision to discharge Coco on 25 July was prematurely reached;
• Coco should have been admitted to the paediatric ward after her presentation in A&E on 25 July;
• Concerns about HUS were not adequately incorporated into a robust management plan;
• There was a delay in taking a stool sample, which was important for identifying the exact type of bacterial infection;
• Throughout the day of 27 July Coco’s fluid management was sub-optimal which was an obvious basic failure of care;
• There was a delay in escalating care internally to ICU colleagues and that, after blood results were returned at 11pm on 27 July, Coco should have been transferred to ICU. This led to an avoidable delay in the escalation of supportive care;
• There was a delay in receiving an answer from Bristol about whether to administer antibiotics and a consultant should have chased this information;
• The combination of the failure to internally escalate whilst waiting for an answer from Bristol made Coco a “hostage to fortune”;
• By 11pm on 27 July there should have been a clear decision on whether to give antibiotics and a rational provided to Coco’s parents about this, and this did not happen.

The inquest had heard evidence from Dr Tse, an expert in paediatric nephrology though, by his own admission, not a specialist in HUS. He agreed that there had been a need for more aggressive fluid management in Coco’s case. However, Dr Tse’s view was that Coco had presented with a very severe form of HUS. Coco did not improve when she was eventually treated in intensive care, demonstrating the aggressive nature of her disease. He came to the view that, even with optimal fluid management, or early escalation to ICU, Coco would still have died. On that basis, HM Senior Coroner accepted Dr Tse’s evidence that, given the overwhelming nature of the HUS Coco developed, the failings in her care were not causative of her death.

In addition, it was heard at inquest that blood cultures reported after Coco’s death did not show bacteria in her blood, which led to the conclusion Coco never had sepsis. Coco’s family have been led to believe for over four years that Coco had sepsis, and a public statement from the hospital Trust said as much. This therefore came as a great shock to them, and remains difficult for them to accept.

The inquest heard evidence that improvements have been made at RCHT following Coco’s death. There have increases in staffing levels, including new consultants for the paediatric department. There has been a roll-out of training and updates to policies. There is now a more comprehensive approach to transfer to a tertiary hospital.

In terms of actions taken to prevent future deaths, the coroner will write to the National Institute for Health and Care Excellence to ask them to consider national guidance on the clinical conundrum of prescribing and administering antibiotics in a patient with suspected/confirmed HUS. RCHT is asked to consider, within 28 days, updates to policies concerned with the care provided to Coco and either explain whether sufficient updates have already taken place, whether they are not necessary, or provide suggested amendments.

Rachel Bradford, Coco’s mother, said in a personal statement she has released, part of which is shared here with her consent: “In the four and a half years since Coco died we have constantly searched for the answers about what happened to our precious daughter… In October 2018 we sat alongside the Trust CEO at a press conference as she ‘fully accepted’ the [findings of the Facere Melius report] which concluded Coco had disseminated bacterial sepsis, and she publicly apologised for the failure to recognise sepsis… Four and a half years after Coco died, three years after the Trust fully accepted a series of failings in their care, we heard for the first time in court the suggestion that Coco did not have sepsis. We also heard one of the doctors admit in court he made mistakes, overlooked things and underestimated the seriousness of Coco’s condition…

We feel that we have been misled for years. The independent report has been removed from the Trust’s website, and they have changed their tune completely… We need some time to come to terms with the latest developments… The nephrologist expert witness said he didn’t claim any special interest in HUS, but he was very certain that none of the failings contributed to Coco’s death. We find his certainty hard to accept… Whatever the court found we will never be able to erase the experience of our time in Treliske from our minds. In many ways we’re left with more questions than answers…

We would like to thank our family and friends, the people of St Ives and elsewhere who have supported us, donated to cover our legal costs, shared their stories and sent words of encouragement and love. We are grateful to the Coroner for ensuring that there was an inquest into Coco’s death. We would also like to thank our legal team, Charlotte Tracy of Barcan + Kirby, and Lorna Skinner QC of Matrix Chambers. Without our barrister offering to act pro bono at the inquest hearing we’re not sure what would have happened. It seems desperately unfair that we have had to crowdfund to cover our legal fees, and rely on our barrister waiving her charges, when the hospital’s legal team are paid for by our taxes.

Coco should now be at secondary school, she should be brightening our lives with her gorgeous smile and living life her best life. We will never come to terms with life without Coco in it.”

Charlotte Tracy of Barcan+Kirby Solicitors who represent Coco’s family said: “It is difficult to put into words my admiration for the strength and dignity Rachel and the rest of Coco’s family have shown in the years since Coco had died and throughout this process. They have suffered the most unbearable loss and have spent too long in a quest to find answers, finding obstacle after obstacle in their way, and having to face new revelations at the very last minute during the inquest hearing itself.

It must be immensely difficult for them to remember their experience in hospital with Coco all too well and for this to guide their intuitive feeling that the failings in her care likely caused her death. On that basis, despite HM Senior Coroner’s finding on causation of Coco’s death, I am grateful to him for his decision to include so much detail in his narrative conclusion, as I think it is very important to Coco’s family that the public know the whole story of what happened to Coco.”

ENDS

NOTES TO EDITORS
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.

Other Interested Persons represented are: Royal Cornwall Hospitals NHS Trust, University Hospitals of Bristol and Weston NHS Foundation Trust, Dr Saul Reales-Diaz, Dr Laura Guilder, Dr Andrew Collinson, and Dr Shama Goyal.

The inquest was live tweeted throughout by activist George Julian at @cocoinquest