Lila Marsland was found unresponsive in bed by her mum and died from meningitis – around eight hours earlier, the five-year-old was discharged from Tameside Hospital as her mum was told she had tonsillitis
“Lila was a person and a beautiful little girl with the rest of her life ahead of her,” said a heartbroken mum, her voice wavering. “It is essential now that the standards of care are drastically improved.”
In the days after Christmas, 2023, little Lila Marsland was enjoying precious time with her family. She’d spent December 27 at Dovestone Reservoir on a walk with her loved ones.
Then she started to get sick. By the evening, Lila’s mum – a district nurse who worked for Tameside and Glossop Integrated Care NHS Foundation Trust – knew it was serious enough to take her daughter to the trust’s A&E at Tameside Hospital.
Lila was suffering headaches, a sore throat, a high heart rate, neck pain and limited neck movement, vomiting, lethargy and was unable to pass urine.
Lila was sent from adult A&E to paediatric A&E. Mum Rachel Micherton asked hospital staff if it was meningitis.
A number of nurses were concerned meningitis was a possible cause for Lila’s illness but, following tests and a review by an experienced paediatric registrar doctor, decided she was more likely suffering from tonsillitis.
The five-year-old was discharged from Tameside Hospital with antibiotics and a throat spray at around 2am on December 28. Around eight hours later, she was found unresponsive in bed by her mum.
She called 999 and attempted CPR. Paramedics arrived, but Lila was pronounced dead at 9.19am.
Ms Mincherton has not returned to work since Lila’s death and was ‘uncertain’ about doing so, as she would ‘need to promote the trust’ that dealt with her child.
More than a year on, an inquest has determined Lila died from pneumococcal meningitis streptococcal pneumonia. A jury determined today (Thursday, June 5) the little girl’s death was ‘contributed to by neglect’.
“Had Lila been admitted to hospital and given broad spectrum antibiotics within the first hour of being triaged, this would have prevented Lila’s death,” the jury concluded.
The trust has apologised and accepted there were failings. The Hyde girl’s death from meningitis was ‘contributed to by neglect’, the jury concluded after an eight-day inquest.
Standing outside Stockport Coroner’ Court, surrounded by her family, Ms Mincherton said: “Today, after eight traumatic days reliving Lila’s death, we welcome the jury’s decision of natural causes caused by meningitis contributed to by neglect.
“On behalf of my family, I would like to thank the jury for coming to this conclusion, based on the evidence provided, a conclusion I have known for 17 months.
“I could not even put into words the pain our family has been left to feel because of the failings that Lila encountered. Throughout the investigation process we have faced continued defences to the care Lila received and whether any shortcomings contributed to her death. We got the outcome today that we believed we should have.
“But hearing the word ‘neglect’ is something a parent should never have to hear and we are now left with the devastating loss of our daughter for the rest of our lives.”
Coroner Chris Morris wrote two ‘prevention of future deaths’ reports, sent to relevant authorities to attempt to stop further deaths from causes uncovered during an inquest.
The coroner wrote to the Secretary of State for Health and Social Care that he ‘remained concerned that the labyrinthine systems’ used across hospitals means there is a ‘real risk of information not following a patient through the system’.
He also wrote to the bosses of Tameside and Glossop Integrated Care NHS Foundation Trust raising fears about its lacking implementation of the National Institute for Health and Care Excellence (NICE) guidance around meningitis, and notes missing from Lila’s case.
The absent notes include a record of the final review of Lila by a senior paediatric registrar before she was fatefully discharged.
Mr Morris also aired concerns that an emergency medicine consultant who approved Lila’s transfer from adult to paediatric A&E ‘provided a statement to this court that they had seen’ Lila ‘and ‘visually assessed [her] at least’.
When called to give evidence in court during the inquest, the consultant admitted this had not happened.
Earlier in the inquest, the hearing was told that in a supplementary written statement to the inquest, Dr Muhammad Farooq said: “In this case, on the request of the staff nurse, I performed a preliminary visual assessment and reviewed the patient’s vital signs.”
However, speaking in the witness box, he said he now accepted that was ‘wrong’ and he had not ‘eyeballed the patient’.
He was asked by Mr Morris if he had been asked to ‘go and see’ Lila by a nurse who was concerned the little one had meningitis. “I don’t remember,” he replied.
“Then why did you write those words, doctor?,” Mr Morris asked. “I reflected and realised my recollection was wrong,” the doctor replied.
“Do you accept, in this case, those words are misleading?,” Mr Morris said. “It implies you had been to see Lila, or seen her from a distance.”
“I accept a mistake,” Dr Farooq said. “I very openly and honestly accept the mistake.”
“Should you have gone to see Lila?” Mr Morris asked.
“If I would have gone to see Lila, in my final assessment I would have transferred the patient in the same manner, to the paediatric emergency department, to get her seen quickly,” he said.
Asked how he knew that, Dr Farooq said: “The department was very busy and there was no space downstairs to see the patient. That was the quickest way to see the patient.”
“To sit in court and listen to statements around the loss of our five-year-old little girl has been a living nightmare,” Ms Mincherton added.
“The failings in care that have led to Lila losing her life is something that must be looked at. We believe serious changes need to be implemented because children should not be neglected when taken to hospital by a concerned parent.
“I sincerely hope that Tameside Hospital can now make serious changes so that another child does not die and another family does not have to go through this horrifying experience.
“The unfortunate care my daughter received was below the standard of how an NHS trust should be treating people.”
A spokesperson for Tameside and Glossop Integrated Care NHS Foundation Trust said: “We want to express our sincere condolences to Lila’s family for their heartbreaking loss.
“It is clear from the independent investigation that there were missed opportunities in Lila’s care. We accept the coroner’s findings and apologise unreservedly for this.
As a Trust, we have made and will continue to make improvements to ensure we learn from this case.”
