Image source, Handouts for families
- author, Adam Reber
- role, BBC News
An inquest jury concluded there was a “missed opportunity” to treat the four-year-old girl, who attended the emergency department and her GP within 48 hours of her death.
Makenna Rose Thackray passed away on December 20, 2022 after she stopped breathing and went into cardiac arrest.
She was taken by ambulance to Pinderfield Hospital in Wakefield two days ago but was sent home after her family waited six hours for treatment. The following day the family visited their GP and were sent home without being prescribed antibiotics.
An attorney for Makena Rose’s family said the evidence shows the little girl’s death was “completely preventable.”
“Shortage of manpower”
Makenna Rose was diagnosed with scarlet fever on December 9, 2022, caused by the bacterial infection Streptococcus A.
An outbreak of Group A streptococcal infections occurred across the UK in late 2022, with pharmacists across the country reporting widespread shortages of penicillin.
The boy was taken to the children’s emergency room on December 18, but the inquest heard that the two nurses on shift that night were looking after around 80 children, rather than the 30 to 40 that could have been safely treated.
Speaking at the start of the hearing, Helen Parker, one of the nurses on that night’s shift, described it as “one of the worst” and, when asked if there had been an understaffing, she replied: “Of course, yes.”
Makena Rose’s mother, Danielle Ledger, took her daughter home because she had not been encouraged to stay.
The nurse said she encouraged Ledger to stay there.
General practitioner Dr Nand Kishar Nemana, who examined her the following day, said he was not aware that Makena-Rose had coughed up blood the previous night or been taken to hospital in an ambulance.
He diagnosed Rothwell’s family with the flu.
Makena Rose died the next day.
Image source, Handouts for families
The court ruled the cause of death to be natural causes, namely invasive group A streptococcal infection and influenza A type 1B (influenza).
Before the case was sent for deliberation, Coroner Oliver Longstaff set out a list of facts which would help the Wakefield Inquest jury reach a verdict.
- Makenna Rose was diagnosed with a PAWS (Pediatric Early Warning Score) of 7 on 18 December 2022 at 20:15 GMT and should have been seen by a mid-level medical professional within 20 minutes of arriving at hospital.
- If the observations had not been made within 30 minutes, McKenna-Rose should have been seen by a consultant.
- Observations were to continue hourly, but McKenna Rose was never seen.
- The girl was supposed to have a blood test but was not able to get one.
- The reasons for not taking the blood test should have been recorded, but this was not done.
- Makenna Rose should have been evaluated with a sepsis screening tool but was not.
The jury found there was a “loss of opportunity” in that Makenna Rose was not observed while she waited in Pinderfield for six hours.
It emerged that McKenna Rose was unable to be seen by a doctor because “the hospital was significantly more busy than usual”.
The jury also found that if Dr Nemana had known Makena Rose had been to hospital and had previously been vomiting blood “his treatment would have been different”.
The inquest concluded following the jury’s verdict.
“Heartbreaking”
Speaking after the incident, solicitor Gareth Naylor said Makena Rose’s family had shown “enormous courage and dignity” in the inquest into her death.
“The evidence presented during the autopsy indicates that her death was entirely preventable,” he added.
“We have approached this inquest in the hope that those responsible for our daughter’s medical care will accept responsibility for their failings, learn from them and ensure this never happens again,” Makena Rose’s parents said in a statement.
They continued: “Even at this stage it is heartbreaking to know that if doctors had rushed Makenna Rose to hospital again, she would likely have survived.”
“Anyone who met Makenna Rose never forgot her.
“She was a larger than life character and a real daddy’s girl.
“She loved dancing and was a huge fan of animals, including her pet rabbit and puppy, Floss, whom she would take to school in a doll’s pram.
“We all miss her so much.”
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