There were “serious failures” in the treatment a baby girl who died at a children's hospital following open heart surgery, a coroner said today.
Hayley Fullerton died at Birmingham Children's Hospital one month after her first birthday after undergoing corrective surgery for a heart condition. She died on November 11 2009, 12 days after being transferred from the hospital's intensive care unit to a general ward.
Her mother Paula Stevenson, who flew to the UK from Australia to attend today's hearing with Hayley's father Bobby Fullerton, has raised concerns about the care given to her baby.
Recording a narrative verdict today at the end of the inquest into Hayley's death Aidan Cotter, coroner for Birmingham and Solihull, said: "The failures by a number of the staff at Birmingham Children's Hospital were serious but not gross."
But speaking afterwards, Ms Stevenson called the staff at the hospital "bullies, cowards and hypocrites" and said Hayley's death was "preventable and predictable".
Ms Stevenson, 40, told the inquest during an earlier hearing that she believed her daughter, who was born in Northern Ireland on October 6, 2008, with a heart defect and a hole in the heart, could have lived if staff at Birmingham Children's Hospital had listened to her concerns.
The court heard that Hayley underwent palliative surgery at the Royal Victoria Hospital in Belfast weeks after she was born. She was then flown to Birmingham Children's Hospital for corrective heart surgery on October 14, 2009.
Ms Stevenson, who is from Northern Ireland but now lives on Australia's Gold Coast, said the operation was a success and Hayley was transferred to the hospital's Paediatric Intensive Care Unit, where she spent 17 days before being moved on to a normal ward.
On November 9 an X-ray revealed that Hayley's right lung had collapsed. She was given physiotherapy the following day but on the morning of November 11 both lungs collapsed and she went into cardiac arrest. She was pronounced dead after a team of doctors spent 20 minutes trying to save her, the inquest heard.
During the hearing Ms Stevenson said her child had been failed "abominably" by medical staff on ward 11, describing her experience as "brutal".
She said staff at the hospital neglected Hayley, "dumped" her at the end of a ward and ignored the family's concerns about her breathing as she recovered from her surgery.
Speaking after the inquest verdict was returned at Sutton Coldfield Town Hall, Hayley's mother said she believed her "beautiful little girl" would still be alive if staff had come to her aid sooner.
Ms Stevenson, who called for the NHS to set up rapid response teams to give patients' families a right to an urgent second opinion, said: "Today is Hayley's day - I have been waiting three years to speak up.
"Hayley died like an abandoned animal - nobody listened to me while Hayley was dying and nobody listened to me when Hayley was dead."
Ms Stevenson added: "Our entire family has been completely devastated by what happened and to this day we continue to grieve for Hayley.
"I still cannot understand how trained medics could ignore the fact that she was slowly deteriorating before their eyes.
"They had seven days to spot that something was seriously wrong but all those precious opportunities were missed.
"My parents and I never left Hayley's bedside during the entire time she was in hospital and it was obvious to us, despite our lack of medical training, that she was a very sick little girl who needed help."
Ms Stevenson, who now plans to sue the trust which runs the hospital, said: "I did all I could to try to get the nurses to help her but my appeals just fell on deaf ears.
"At one point, after I had complained that Hayley wasn't getting the treatment she needed, she was moved to an isolation room, with staff claiming she might have swine flu.
"This diagnosis was later found to be completely wrong but it meant we were moved even further from the nurses' station and couldn't attract their attention easily.
"It was as though Hayley had been placed in isolation as a punishment for me daring to speak up on her behalf."
In an internal review of Hayley's death, the NHS found that a "hierarchy" among medics deterred junior staff from referring Hayley back to a paediatric intensive care unit in the days before she died.
Ms Stevenson added: "It is to their shame that not one of them saw fit to ask for an urgent second opinion."
In a statement issued after the coroner's verdict, the Birmingham Children's Hospital NHS Foundation Trust said: "When Hayley died we recognised that some of her care fell below our usual high standards and for this we offer a heartfelt apology for the distress that has been caused.
"We've taken all the steps possible to learn from this.
"We've gone beyond the recommendations of our investigation and improved the way we do things to ensure that no children or families experience anything like this again."
In his summing up of the evidence and narrative verdict, Mr Cotter said he could only make a finding of neglect if there had been a "gross" failure to provide medical attention which had a sufficient causal connection to the death.
Ruling that the failings in Hayley's care were serious rather than gross, the coroner said the evidence at the inquest had not supported the hospital's finding that junior staff were "uncomfortable" about referring patients to the paediatric intensive care unit.
Listing the failures, Mr Cotter said he was satisfied that Hayley should have been referred to a children's intensive care unit two days before her death.
The coroner was also critical of a delay in providing physiotherapy to Hayley and other aspects of her care, including inaccuracies in medical records.
"Nobody will ever know whether Hayley would have made a successful recovery," the coroner said. "However it is indisputable that Hayley would have had a better chance of survival if she had been referred to the paediatric intensive care unit on November 9."
Medical specialists at law firm Irwin Mitchell, who have represented the family in their three-year battle for answers, said the hospital trust had now fully admitted that a catalogue of failings was responsible for Hayley's "tragic and avoidable" death.
During the inquest, which heard evidence in April, May and September, it emerged that an internal investigation found a "hierarchical culture" among staff on one ward had contributed to the decision not to return Hayley to intensive care.
Mandy Luckman, a medical law expert at Irwin Mitchell's Birmingham office, said: "Given the trust has now admitted full liability, there needs to be an urgent review to determine whether the system failings put to the trust during the inquest, and as accepted in the trust's own internal investigation report, have now been remedied.
"Hayley's family - and indeed any parent whose child requires critical care at Birmingham Children's Hospital - need reassurance that all clinical and nursing staff now clearly understand the criteria for a young patient needing urgent referral (to intensive care).
"We also hope that the trust has taken steps to remove the old hierarchical culture at the hospital which, in effect, prevented medical staff from doing their job.
"Although nothing can turn back the clock for Paula and her family, who continue to suffer the most unimaginable heartache, they are determined that Hayley's death will not be completely in vain and will hopefully create a catalyst for change in the NHS."