Girl, two, who died from meningitis after wrongly diagnosed with swine flu was let down by the emergency services, coroner rules
Coroner returned a narrative verdict and ruled Georgia died following an 'erroneous diagnosis'Georgia's mother called for an ambulance after she was told by swine flu hotline it was unlikely to be swine flu. But paramedic sent ambulance away and gave her TamifluSecond ambulance called out four hours later after Georgia stopped breathing. She was pronounced dead when she got to hospital
15:18 GMT, 3 October 2012
Natasha Keeling was told to give her daughter Georgia Tamiflu
A two-year-old girl who died after she was wrongly diagnosed with swine flu was failed by emergency services, a coroner has said.
Georgia Keeling, from Norwich, died from a meningitis-like infection following the incorrect diagnosis at the height of the 2009 national pandemic.
The inquest in Norwich heard that paramedic Patricia Perfect had examined her at home but sent an ambulance away because it was 'another case of swine flu'.
Four hours later, following a second 999 call, the toddler was rushed to hospital where she died.
Returning a narrative verdict today, Norfolk coroner William Armstrong ruled Georgia died following an 'erroneous diagnosis' and the fact she was not immediately admitted to hospital reduced her chances of survival and contributed to her death.
He said: 'She died from a condition that was previously undiagnosed and the examination by Miss Perfect was inadequate and deficient and there was a failure to recognise the severity of her condition.
'Is is possible Miss Perfect was over-influenced by the fact there was at the time a prevalence of swine flu
'There is no doubt at all that Georgia should have been sent to hospital immediately and she would have had a better chance of survival.'
A fantastic girl: Georgia was misdiagnosed with swine flu when she was suffering from meningitis
Georgia's parents (pictured left) Paul Sewell and Natasha Keeling have spoken out to highlight a catalogue of failings that led to the death of their daughter Georgia (pictured right)
He added that the East of England Ambulance Trust had already taken action to reduce the likelihood of future tragedies.
Earlier in the hearing it was suggested Georgia’s death on August 4, 2009 was the result of meningitis.
Today, pathologist Xenia Tyler said a
post-mortem showed she died from a group A streptococcal infection, a
rare form of blood poisoning which can develop into meningitis.
Georgia was first seen by Miss Perfect at about midday on August 4, 2009 following a 999 call.
Her mother, Natasha Keeling, said she
had initially felt relieved that she had been diagnosed and given the
swine flu medication Tamiflu.
Georgia’s father, Paul Sewell, said he had been reassured it was not life-threatening.
But her condition continued to
deteriorate and Ms Keeling again dialled 999 shortly before 4pm. Georgia
was pronounced dead at the Norfolk and Norwich University Hospital at
Georgia was taken to the Norfolk and Norwich University Hospital, but she was pronounced dead on arrival
Meningitis symptoms to look out for
Professor John Kroll told the inquest
that, on the balance of probabilities, it was likely Georgia would have
survived if she had been taken to hospital sooner.
He added: 'The diagnosis of swine flu was clearly inappropriate. The circumstances here go far outside
what any clinician would diagnose as swine flu. If it was swine flu, it
was swine flu with complications.'
Dr Jeffrey Perrin, a paediatric and
intensive care consultant who examined the circumstances around her
death, said “red flag” warning signs were missed.
Paramedic Patricia Perfect said she visited the family's home and made the swine flu diagnosis after a 45-minute examination
He added: 'I would not necessarily
have expected an emergency care practitioner to have diagnosed the
illness but it is more important to recognise the severity of the
'The failure of an emergency care
practitioner to recognise the severity of Georgia’s illness resulted in
her having a reduced chance of surviving the illness.'
Miss Perfect yesterday told the
hearing she regretted the incorrect diagnosis but said “most clinicians”
would have made the same mistake given the unprecedented circumstances.
She described how medics had been 'distracted' by the pandemic.
'Swine flu was at the forefront of
everybody’s mind. Had that not been a factor I would have been looking
at other reasons,' she said.
Speaking outside the inquest, Mr Sewell said the last three years had been like “going through hell”.
But he said the family accepted that the ambulance service had learnt from the mistake.
He added: 'We were failed by one person and we can't blame the whole NHS for that.'
He and Ms Keeling issued a statement saying: 'Nobody knows a child like their parents and we are saddened that despite our best instincts the ambulance service failed to provide adequate care to Georgia.
'We are pleased the ambulance service has apologised for the failings of its emergency care practitioner – we are only sorry that it has taken three years.'
Speaking after the inquest, Dr Pamela Chrispin, medical director and deputy chief executive at the East of England Ambulance Service, offered her “deepest condolences” to Georgia's family.
She added many children with fever and a rash are safely seen, treated and left at home.
Dr Chrispin said the ambulance service had apologised for the shortcomings and was pleased the coroner had acknowledged the progress that had been made.
'In Georgia's case we accept that, although the paramedic carried out an assessment and followed national guidance, she could have identified the potential for Georgia to become more seriously ill and arranged urgent admission to hospital,' Dr Chrispin said.
'She has since undergone a period of retraining and evaluation and has returned to frontline duties.
'This is a difficult area for all healthcare professionals involved in the assessment of children in the community and, as in this case, sadly there is occasionally a tragic outcome.
'Since Georgia's death the East of England Ambulance Service have taken additional steps to help our staff recognise and manage seriously ill children.
'We are the leading ambulance service in the UK to work with the international Surviving Sepsis campaign, which promotes the early identification and treatment of sepsis.'