Kettering Hospital says lessons have been learned after a disabled nine-year-old girl died three weeks after being admitted with a tooth infection.
Daisy Healy, of Kettering, who had complex medical conditions and learning difficulties, was admitted to Kettering General Hospital on three occasions after bleeding from where three teeth has been taken out.
The cause of the infection was never established and Daisy’s condition deteriorated badly until she was taken to a paediatric intensive care unit at Leicester Royal Infirmary.
She died there the next day on October 10, 2005, from bleeding in the lungs, a severe infection and blood disorder.
After her death, her mother Amanda fought for an investigation and eventually secured a report from the Health Service Ombudsman.
The findings of the investigation given to Amanda in December 2010 found both Daisy and her family had suffered an injustice.
Daisy’s case has now been highlighted by disability charity Mencap as one of 74 where the NHS discriminated patients with learning difficulties.
Amanda said: “Daisy, throughout her short life, never failed to turn any disadvantages into advantages and squeeze every bit of joy from every possible moment.
“She was admitted to Kettering General Hospital and discharged two times before becoming an inpatient.
“From this time simple treatment that was suggested and readily available, which could have saved Daisy’s life, was not attempted.”
She added: “Members of staff carried out duties which contradicted the critical nature of daisy’s condition and would have hastened her death.
“Because no definitive treatment had been undertaken to treat Daisy her situation progressively deteriorated until she had multiple life-threatening conditions.”
The ombudsman could not conclude Daisy’s death was avoidable, but said failures led to missed opportunities which may have led to a different outcome for Daisy.
The ombudsman said the trust did not have regard to its obligations under disability discrimination law, did not act in accordance with good practice, did not plan and prioritise resources to meet dutues and did not communicate with parents.
It added: “I also find that in consequence of this service failure, Daisy and her family suffered injustice.”
In response, Kettering General Hospital chief executive Lorene Read said the hospital had learnt lessons from the incident.
She said: “We have offered our sincere apologies to Daisy’s family for the care she received at Kettering General Hospital in 2005 and have learned lessons from it.
“Over the last four years the trust has made very significant efforts to establish good practice around our care of both children, and adults, with learning disabilities.
“Even before the Ombudsman’s report into Daisy’s death was published we had started to make significant changes to improve care for families with members who have learning disabilities.
“And we have addressed the specific issues raised within the Ombudsman’s report of improving effective communication with parents, preventing any kind of discrimination, and prioritising resources to ensure care is of a high standards.”
In a statement, Kettering General Hospital Trust said improvements had been made since the incident.
They include a passport system for children with learning difficulties so that anyone who deals with the child is fully aware of their conditions.
The trust has also introduced a communication sheet which is placed by each bed to give parents a chance to write questions and get answers so they can have a clear idea of what is happening.
Compulsory training in learning disabilities has been brought in for staff, a learning disability project worker hired and a resource pack on the subject made up.