Doctors 'missed opportunities' to save Chloe Longster's life, says senior medic who reviewed her case

The paediatric consultant asked by KGH to review the circumstances surrounding the death of Chloe Longster said that staff were ‘sidetracked’ by the fact she was asthmatic.

Jothsana Srinivasan, of Nottingham University Hospitals Trust, told the fourth day (Thursday, October 10) of an inquest at Northampton Guildhall that staff should have taken Chloe’s blood pressure when she arrived at the emergency department which may have helped them start to think ‘along the lines of sepsis’.

She said that doctors made a plan when assessing Chloe on her admission on the afternoon of November 28, 2022, but that there was ‘no implementation’ of it.

On the first day of the inquest Chloe’s mum Louise told the hearing that her daughter had never had an asthma attack but had inhalers to help with wheezing during intense exercise.

Dr Srinivasan said: “It was not clear whether her asthma was well-controlled. No adequate history was done in the emergency department to assess that.

"They were sidetracked in terms of management.”

The doctor said that staff on the Skylark ward had not been prepared to accept Chloe with such a high Paediatric Early Warning System (PEWS) score, which at that time was five.

"They didn’t understand how unwell she was,” said Dr Srinivasan.

She said doctors should have reviewed Chloe much earlier and should have implemented hourly observations because of her PEWS score.

Dr Srinivasan also said that Chloe, from Market Harborough, should have been given antibiotics and fluids earlier.

"That was a missed opportunity,” she said.

In the early hours of November 29, Chloe began to deteriorate further and doctors continued to treat her for a serious asthma attack, alongside her pneumonia.

"There’s been a confirmation bias,” said Dr Srinivasan.

A consultant who attended to Chloe late in the evening said that he thought antibiotics had already been given.

"There were assumptions,” said Dr Srinivasan.

“The consultant became too task-focused and when the lead becomes task-focused.. the overview becomes lost.

"There were multiple opportunities where intervention could have happened.. which would have altered the outcome.”

It was only in the early hours of the morning that her sepsis was fully recognised by those treating Chloe.

Earlier today, University Hospitals of Northampton Medical Director Hemant Nemade gave evidence before coroner Sophie Lomas.

In a letter sent to Chloe’s family, Mr Nemade – who has been in post for three months – said he recognised that there were ‘missed opportunities to recognise and respond’ to Chloe’s condition.

He told the inquest: “We could have done better in terms of monitoring her and communicating with her family.”

But the family’s barrister, Rachel Young, read an extract from an earlier letter sent to the Longsters in March 2024 by Northampton General Hospital NHS Trust.

The letter said: “Had Chloe’s worsening condition been appropriately recognised and the sepsis pathway actioned, it’s likely her death could have been prevented.”

In a series of heated exchanges, Mr Nemade was asked by Ms Young repeatedly about whether, on the balance of probabilities, Chloe’s death could have been prevented.

He persistently refused to be drawn on the statement and answered in several different ways, saying: “We could have done 100 per cent better. Whether the outcome have been affected is unpredictable," and “Chloe was very sick, there’s no guarantee.

"Sepsis has an unpredictable outcome. It’s got a high mortality rate.”

Ms Young was eventually told by the coroner to stop asking the question. She said: “This witness is not being pinned down to the balance of probabilities,” adding that those present could take their own inferences from his answers.

Mr Nemade outlined the ways in which Kettering General Hospital had made improvements as a direct results of Chloe’s death two years ago.

He said that there was a now a three-strong sepsis team that was in each ward daily to check and audit whether sepsis procedures were being followed.

Staffing had been increased to ensure that two consultants remained on site when on-call in the evening.

This morning, Dr Laszlo Hollos, who treated Chloe in the hours before her death, told the inquest that he had been asked for his view on Chloe’s care while he was treating another poorly child.

The consultant anaesthetist, who specialises in critical care, was asked for his opinion on whether the team should intubate Chloe, who at that point was in distress.

He decided to go and see her.

"She looked at me and she opened her eyes but she wasn’t strong enough to give me a reply,” said Dr Hollos.

"I was told that her primary problem was asthma.”

By then Chloe had had an x-ray which showed her condition was worsening.

Dr Hollos decided that intubating Chloe to help her breathe was the best course.

The coroner asked Dr Hollos whether intubating Chloe earlier may have helped her chances of survival.

He said: “Over a few hours she developed signs of multi-organ failure. The sepsis was progressing very rapidly.

"I can’t say that intubating her a couple of hours before would have helped. There is a possibility.”

When Chloe was intubated she had a cardiac arrest, which Dr Hollos said his team was a known risk and for which they were prepared for.

She was resuscitated and her circulation returned, but she died just before 7am.

Read our previous coverage of the case here and here.