Hospital neglect contributed to baby death - inquest

Neglect by hospital staff contributed to the death of a five-month-old girl from meningitis after a series of missed opportunities to save or prolong her life, an inquest jury has found.

Esta High died at Leeds General Infirmary in November 2023, days after she was taken into the emergency department with a high temperature and vomiting.

Her parents claimed doctors missed vital chances to test for a bacterial infection and start antibiotic treatment, with her mother saying their concerns were ignored until it was too late.

A jury concluded on Tuesday that Esta "died of natural causes contributed to by neglect" and different care would probably have "saved or prolonged her life".

Opportunities were missed as doctors stuck to their diagnosis of Covid after Esta tested positive for coronavirus, the jury said.

There was no dispute that Esta's cause of death was streptococcus pneumoniae meningitis, the court heard.

Lawyers for Leeds Teaching Hospitals NHS Trust admitted during the inquest at Wakefield Coroner's Court that there had been missed opportunities to diagnose the bacterial infection which causes meningitis and to give Esta antibiotics.

Her parents, Lynsey Carr and Leon High, had told the jury how Esta was a "happy, healthy, smiling girl" before she became ill on 31 October 2023.

Her parents took her to Leeds General Infirmary as she was suffering from a high temperature and vomiting, and she later tested positive for Covid.

Carr told the inquest how the family, from Leeds, was put in a side room at the hospital's children's assessment and treatment (CAT) unit where she believed staff were more concerned with isolating Esta due to the Covid risk than listening to her parents.

Carr said she and her husband had refused advice from doctors to take Esta home as she had a temperature that soared to over 40C and she would not stop vomiting.

She said she feared her daughter was having a seizure after she developed a rash and her arm started shaking, which High filmed - a video shown to the inquest jury.

Carr told the jury she and High were "extremely worried" and "we kept asking for help", but "staff were rude and don't listen to our concerns".

Esta's time on the CAT unit was "15 hours filled with missed opportunities", Carr said.

By late afternoon on 2 November, Esta could not be roused and the inquest jury heard how scans and other tests showed evidence of meningoencephalitis and streptococcus pneumoniae.

Esta was taken to intensive care and attempts were made to save her life, but she died on 6 November.

Carr told the jury: "Unfortunately, as our daughter had been left untreated for 55 hours, it was too late to save our darling girl."

She said her daughter was "bright, beautiful and perfect from the first moment", and "when she arrived, she completed us".

"Her smile lit up every room – especially in the mornings, when she woke as if full of joy just to see us again. She brought happiness everywhere she went," she added.

Speaking outside court after the verdict, Joe Haley, the family's solicitor, read a statement on behalf of Esta's parents.

In it, Carr - speaking for both her and High - said Esta's birth was "a moment we had dreamed of, and we were overwhelmed with joy and love".

Carr said when at Leeds General Infirmary, their concerns were not taken seriously by hospital staff and they were "made to feel we were anxious and overprotective parents".

Esta "passed away lying between me and Leon, something no parent should ever have to go through," she said.

However, the couple said they hoped that by sharing their experiences, they could "help improve care for others" and called for parents' concerns to be "listened to and taken seriously".

"If we can prevent what happened to Esta happening to other families, then her death won't have been totally in vain," they said.

In a separate statement, Haley said Carr and High's concerns over their daughter's care were "validated" by "worrying evidence" presented at the inquest.

"It is now vital that lessons are learned to improve patient safety and prevent others from going through the terrible suffering Esta's family has endured," he added.

In a statement, Dr Elizabeth Garthwaite, chief medical officer at Leeds Teaching Hospitals NHS Trust, said: "We are deeply sorry we failed Esta and her family, and offer our sincere and heartfelt condolences to Lynsey and Leon following the tragic death of their daughter.

"We are grateful to the coroner and jury for their careful consideration of the circumstances surrounding Esta's death.

"We recognise the immense pain and loss experienced by Esta's family and acknowledge that nothing can change what happened or lessen the grief they continue to live with every day."

Garthwaite said the trust "fully respects" the jury's findings and the coroner's decision to issue a prevention of future deaths report.

"We recognise that serious failures occurred in the care provided to Esta and that these failures had devastating consequences," she said.

"We take the concerns raised by the coroner extremely seriously and will carefully consider the report's findings and recommendations. We are committed to responding openly and fully, and to taking any further action necessary to improve patient safety."

Garthwaite added the trust had already taken steps to "strengthen" its services, including improving the recognition and management of deteriorating children, enhancing staff training in paediatric sepsis, strengthening escalation processes and implementing Martha's Rule to "help ensure concerns raised by patients and families are heard and acted upon".

She added: "We will continue to review our practices in light of the coroner's findings and any additional lessons identified.

"We remain committed to learning from what happened to Esta, listening to patients and families and doing everything possible to provide safe, compassionate care for every child and family entrusted to our services."

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