A coroner today criticised medical staff for not sharing information about a toddler who died after her meningococcal septicaemia symptoms were missed.
Eighteen-month-old Fatama Barkhad was sent home from the University Hospital of Wales, Cardiff, in the early hours of October 6 last year after a doctor diagnosed her as having a sore throat.
Her mother Hana Ismail was told by Dr Shyama Velupillai to give the little girl Calpol and seek medical help if her condition got worse.
Less than five hours later, Fatama was rushed back to hospital after developing a rash on her head and body.
Doctors battled to save her, but she died of meningococcal septicaemia, a type of blood poisoning, the same day.
The first time she was taken to hospital, Fatama was examined by a paramedic, then a triage nurse and finally Dr Velupillai, a GP working for an out-of-hours service.
The inquest heard none passed on accurate information about the little girl's condition, including her breathing rate and heart rate.
Cardiff Coroner Mary Hassell said this was "worrying", but concluded that Fatama's treatment would have been the same if all the information was available.
She said: "I find it extremely unfortunate that out of three medical professionals, none saw the record of those going before them.
"The triage nurse did not see the record made by the emergency technician, and the general practitioner did not see the record made by the triage nurse, or the emergency technician.
"It seems to me a very, very unsatisfactory state of affairs."
Ms Hassell told the inquest she has written reports to the Cardiff and Vale NHS Trust and the Welsh Ambulance Services NHS Trust to voice her concerns.
She said she was also concerned there were no written guidelines for triage nurses to follow when presented with a sick child, and added: "This cannot be satisfactory."
But she concluded: "Given all of the evidence, I don't think, if the history had been taken accurately and the earlier observations had been known about, that ultimately this would have changed the course of events for Fatama."
The coroner said she did not know if Fatama would have survived even if she had been admitted to hospital on her first visit.
She added: "I can't see whether, even if the course of events had been different, and even if Fatama had been kept in hospital, the outcome would have been different for her. I simply don't know."
Dr Hugo Dowd, paediatric accident and emergency consultant at the University Hospital of Wales, told the inquest that one in 20 children with the disease cannot be saved, no matter how early it is spotted.
Ms Hassell recorded a narrative verdict, outlining the events surrounding Fatama's death.
Fatama's parents, Ms Ismail and Mustefa Barkhad, of Butetown, Cardiff, did not wish to comment after the inquest.Reuse content