Girl, 9, told she had tonsillitis and sent home 'could have been saved'
A coroner has said that a girl who died from a cardiac arrest the day after being misdiagnosed in the middle of a Strep A outbreak could have been saved.
Despite pleas by her parents for a course of antibiotics as news of the deadly outbreak hit headlines, Riya Hirani, aged just nine, was sent home from Northwick Park Hospital, in Harrow with a piece of paper and advice to use over-the-counter painkillers.
Riya, of Wetheral Drive in Stanmore, was discharged on December 22, 2022 after being taken to the North West London hospital by her mum and dad on advice from NHS 111. Her parents were worried that she'd gone through a three-day fever, redness in her throat, and difficulty speaking. But the Senior House Officer (SHO) who assessed her decided she was "not very sick" and discharged her with a diagnosis of viral tonsillitis.
Riya was sent home from Northwick Park & St Mark's Hospital (AFP via Getty Images)Riya's mum Geeta saw white pus in the back of her daughter's throat the next evening, on December 23, and panicked. She decided to return to hospital but as they were leaving, Riya's dad Mukesh thought she was choking and patted her on the back. She collapsed and went into cardiac arrest, suffering severe brain damage that ended her life in Great Ormond Street Hospital (GOSH) five days later, My London reports.
Ms Hirani told St Pancras Coroner's Court during an inquest into her daughter's death on Thursday: "We were literally leaving and she stood up and said she could nor breathe. It was so quick. I do not understand how it could happen so quick." Her parents recalled their delight after a 10-year battle to conceive was successful by IVF.
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"She was very active, loved to sing and dance, and do arts and crafts. She was a bright and smart girl," added Ms Hirani. "She adored Lego. She would spend hours playing with her little sister, making up characters with her Lego. She had a very mature understanding of the world."
It was only after Riya's tragic death doctors at GOSH were able to confirm she had been infected with Group A Streptococcus, a bacterial infection that, in its most invasive form, can be fatal. Her death came after an outbreak in early December 2022, with around 30 children thought to have succumbed to the infection between September 19 and December 30, according to UKHSA data.
This meant that an alert about the infection would have been issued to staff at hospitals across the UK, including Northwick Park. However, during the inquest, senior consultants from Northwick Park Hospital and GOSH both questioned Riya's care after she arrived at the hospital with relevant symptoms.
The SHO involved in assessing Riya said he looked for five criteria when deciding if a child might need admission for Strep A, including a fever lasting more than 24 hours, an absence of cough, pus on the tonsils, attending hospital within three days of illness, and severely inflamed tonsils.
The doctor told the court Riya met two of the criteria – having had the fever and attending hospital within three days – but said he found no pus and her parents had reported her coughing. However, the redness of Riya's throat, linked to the inflammation of her tonsils, became a point of contention as he was questioned by Coroner Mary Hassell.
Ms Hirani took the witness stand and claimed the SHO had told her Riya's throat was "very red", which did not match his patient notes where it was noted that it was just "red". The doctor denied he meant "severely red" when he spoke to Ms Hirani, but admitted: "Sometimes when you write very quickly you miss some words." Later he admitted if he had spotted the third warning sign, he may have raised the issue with a senior doctor to look at more closely.
Coroner Hassell said: "Could it have been it was severely red?" The doctor replied: "No it was not severely red. I usually write a positive finding very clearly." He was also asked why he failed to note down Riya's neck pain. He replied: "Maybe I forgot, I do not know. It's very common that nine-year-olds present with neck pain."
The doctor was quizzed over his failure to spot Riya's "difficulty speaking", despite concerns raised by her parents. "I cannot remember that phrase," he told the court. "But I was told her voice had changed, rather than she was not able to speak, as far as I can remember."
"She was using all her breath to get her words out, that's what was happening and I explained that," Ms Hirani told the court. "When I examined her she did not have any difficulty breathing," the doctor responded.
In a number of tearful submissions, Ms Hirani repeatedly called the doctor's professional judgement into question. "I know as a mother she was really sick as for nine years she had never been that sick," she said. "I remember saying this could be Strep A, I can't find a rash though. I left it for you medical professionals to find out."
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Asked if he would do anything differently, the doctor said: "I would try to keep my notes as neat as I could and try to write everything. If I was worried about anything I would go to see my senior. I would try to check the blood pressure of the patient." He added: "Sometimes we can't predict the future."
Consultant in paediatric intensive care at GOSH, Dr Quen Mok, remembered Riya arriving at the specialist children's hospital in Camden after 11 minutes of no cardiac output and evidence of brain swelling. Tests found Riya was Influenza B positive, but Dr Mok suspected there might be another issue. "Having done 30 years of paediatric care I had never seen a child with influenza be so sick," she said.
Riya was sedated and put on a ventilator to prevent further brain injury, but her brain continued to swell and her pupils began to dilate. Riya sadly died in hospital on December 28 with her medical cause of death given as 1A hypoxic ischemic brain injury, 1B out of hospital cardiac arrest, and 1C Strep A and Influenza infections.
Asked if Riya would have survived if given antibiotics, Dr Mok said: "At least you would have felt it gave her a chance and treated her. I do not know if it would have prevented the cardiac arrest. I think if Dr Jadou had seen her he probably would have admitted Riya to the paediatric ward and started her on IV. And even if she had a cardiac arrest, it would have been in hospital where treatment is quicker."
In a narrative judgement, Coroner Hassell said: "I'm satisfied from all the evidence at the point [Riya] was brought into hospital she was showing signs and symptoms of a bacterial infection and should have been treated as such.
"She should have been admitted and treated with antibiotics. I'm not certain what the outcome would have been, but I am satisfied on the balance of probabilities, if Riya had been appropriately treated she would have survived."
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