Verdict in Coco Bradford inquest Cornwall: death not from sepsis

Coco Bradford died aged six years old at Bristol Royal Hospital for Children on July, 31 2017 from multiple organ failure and haemolytic uraemic syndrome (HUS) - a condition caused by E.coli - at Bristol Royal Hospital for Children on July 31 2017.

It had been previously reported that Coco had died of sepsis and, at the end of today's inquest, Coroner Andrew Cox concluded that this had not been the case.

In his conclusions, the coroner said: "Coco did not have sepsis.

"The result of a stool culture from Bristol was open to misinterpretation that Coco did have sepsis.

"The Trust’s former Chief Executive mistakenly said in a public apology that the Trust failed to recognise sepsis and the suggestion Coco died from sepsis has, as I understand it, been widely mis-reported in both local and national media.

"It is, in my judgment, in the public interest to correct the position.

"Coco died from natural causes, in particular, a severe form of haemolytic uraemic syndrome, a known but rare complication of an e-coli 0157 bacterial infection."

Coco had initially been admitted to Royal Cornwall Hospital while suffering from vomiting and diarrhoea on July 25.

However, after her condition appeared to stabilise, she was discharged.

She was then readmitted after her condition further deteriorated and was given a working diagnosis of bacterial gastroenteritis.

Coco was treated with fluids and seemed to improve, however, these improvements could not be sustained and Coco continued to deteriorate.

Coco Bradford. Picture: Bradford family/ SWNS

She was then transferred to Bristol Royal Hospital for Children where, despite further treatment, Coco passed away.

The coroner also found that doctors had missed several symptoms and delayed basic care such as fluid management, but this was not found to be causative.

Coroner Andrew Cox said: "I find as fact that there was a delay in Coco starting to receive appropriate fluid therapy.

"This delay is particularly important when dealing with a disease like HUS where all the available literature suggests that best outcomes are seen after early fluid expansion."

The coroner also accepted that the decision not to admit Coco to the Paediatric Unit upon her arrival did not contribute to her death after hearing evidence from Dr Yincent Tse, a consultant paediatric nephrologist at Great North Children’s Hospital in Newcastle Upon Tyne who claimed that he did not believe Coco could have been saved.

Cox also gave Royal Cornwall Hospital 28 days to provide evidence that it had issued new guidance when treating patients like Coco.

He also said he would be writing to NICE requesting it issue new guidance for the treatment and diagnosis of HUS.

Coco’s family said in a statement published by PA that they needed time to come to terms with the conclusions of the inquest, adding: “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.”

They said that further disclosures about failings in Coco’s care made them feel that “we have been misled for years”.

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

Royal Cornwall Hospitals Trust medical director, Dr Allister Grant, said: “Today the Coroner has provided his conclusions following an inquest into the death of six-year-old Coco Bradford.

“We entirely accept his conclusions and profoundly regret the failings in the care Coco received. While the Coroner has concluded, based on the expert evidence, that different treatment would not have avoided Coco’s tragic death, this does not take away from the fact that we let Coco and her family down. This is a matter of deep sorrow to those who cared for Coco, as was acknowledged during the inquest.

“We also regret Coco’s family has been caused additional distress by the belief that Coco’s poorly condition was explained by sepsis, as opposed to an overwhelming inflammatory condition called HUS (Haemolytic uraemic syndrome). We note the Coroner has concluded on the evidence presented during the inquest that Coco did in fact not have sepsis.

“The quality and safety of the care received by each and every patient is our highest priority. Following an independent investigation into her death a detailed action plan has been fully implemented and we will now ensure we review the Coroner’s conclusions with great care to identify any further learning that can improve the provision of care to children, including those with learning difficulties.”