The hospital that sent Lila Marsland, 5, home with fatal meningitis PRAISED by inspectors a year on from tragic death

An inspection by the health watchdog, 13 months after Lila’s death, found praised the hospital that sent the five-year-old girl with tonsillitis medication just hours before she died from meningitis

A Greater Manchester hospital has been praised by health inspectors – just a day after an inquest found that neglect by the hospital ‘contributed’ to the death of a little girl.

In December 2023, Lila Marsland had been sent home from the Tameside General Hospital’s paediatric A&E with treatment for tonsillitis, despite nurses suspecting she had meningitis.

She was found unresponsive just eight hours after being discharged, dying from the life-threatening condition.

Just over a year after Lila’s death, and a day after the inquest findings, the hospital’s services for children and young people have been rated good by the health watchdog.

An inspection was carried out in January by the Care Quality Commission (CQC), and the report published today (June 6).

The inspection was carried out in ‘response to concerns received about serious incidents within the service’, said the watchdog.

But inspectors say they did not find any areas where children and young people were being placed at risk of harm.

Following Lila’s death, the coroner raised concerns about a ‘lack of clarity’ over escalation procedures at the hospital, revealed by evidence given in court around the little girls’ case.

But the CQC’s report says that, during the January inspection, hospital staff ‘were aware of how to escalate key risks that could affect people’s safety, such as staffing and bed capacity issues and there was daily involvement by ward managers, clinical leads and matrons to address these risks’.

An inquest in Lila’s death was held over eight-days over the last week, culminating in a conclusion just yesterday (June 5) in which a jury found that ‘had Lila been admitted to hospital and given broad spectrum antibiotics within the first hour of being triaged, this would have prevented Lila’s death’.

Lila’s mum, from Hyde, said it is a ‘conclusion I have known for 17 months’. “I could not even put into words the pain our family has been left to feel because of the failings that Lila encountered,” she explained.

“Throughout the investigation process we have faced continued defences to the care Lila received and whether any shortcomings contributed to her death. We got the outcome today that we believed we should have."

On December 27, 2023, Lila’s mum – a district nurse who worked for Tameside and Glossop Integrated Care NHS Foundation Trust – knew her daughter was unwell enough to take her to Tameside Hospital’s A&E.

Lila was suffering headaches, a sore throat, a high heart rate, neck pain and limited neck movement, vomiting, lethargy and was unable to pass urine.

Lila was sent from adult A&E to paediatric A&E. Mum Rachael Mincherton asked hospital staff if it was meningitis.

A number of nurses were concerned meningitis was a possible cause for Lila’s illness but, following tests and a review by an experienced paediatric registrar doctor, decided she was more likely suffering from tonsillitis.

Lila was discharged at 2am with some antibiotics and a throat spray.

Around eight hours later, she was found unresponsive in bed by her mum. The mum called 999 and attempted CPR. Paramedics arrived, but Lila was pronounced dead at 9.19am.

Ms Mincherton has not returned to work since Lila's death and was 'uncertain' about doing so, as she would 'need to promote the trust' that dealt with her child.

Some 17 months later, the inquest has determined Lila died from pneumococcal meningitis streptococcal pneumonia. A jury determined the little girl’s death was ‘contributed to by neglect’.

Coroner Chris Morris wrote two ‘prevention of future deaths’ reports, sent to relevant authorities to attempt to stop further deaths from causes uncovered during an inquest.

The coroner wrote to the Secretary of State for Health and Social Care that he ‘remained concerned that the labyrinthine systems’ used across hospitals means there is a ‘real risk of information not following a patient through the system’.

He also wrote to the bosses of Tameside and Glossop Integrated Care NHS Foundation Trust. He highlighted the hospital’s lacking implementation of the National Institute for Health and Care Excellence (NICE) guidance around meningitis, and notes missing from Lila’s case.

The absent notes include a record of the final review of Lila by a senior paediatric registrar before she was fatefully discharged.

Mr Morris also aired concerns that an emergency medicine consultant who approved Lila’s transfer from adult to paediatric A&E ‘provided a statement to this court that they had seen’ Lila 'and ‘visually assessed [her] at least’.

When called to give evidence in court during the inquest, the consultant admitted this had not happened.

The inquest findings coincided with the publication of the CQC’s report. The services for children and young people at Tameside Hospital had previously been rated good by the inspectors, and that rating was given again.

The services include a dedicated children and young people’s emergency department and paediatric outpatient department, a neonatal intensive care unit (NICU) and a children’s unit, which includes paediatric day surgery and an observation and assessment area.

The hospital also provides children’s community nursing services.

Among the main findings of the inspection were:

• "Staff considered children and young people’s specific needs, wishes and preferences in their care plans
• "The service had processes to support young people with long-term conditions such as epilepsy, asthma and diabetes when transitioning to adulthood
• "Children and young people were cared for by kind, supportive and respectful staff
• "Staff were aware of how to escalate key risks that could affect people’s safety, such as staffing and bed capacity issues and there was daily involvement by ward managers, clinical leads and matrons to address these risks
• "Children and young people’s cultural and social needs were understood and met. Most staff had completed autism awareness training and equality, diversity and human rights training."

Tameside General Hospital, in Ashton-under-Lyne, is managed by Tameside and Glossop Integrated Care NHS Foundation Trust.

A spokesperson for Tameside and Glossop Integrated Care NHS Foundation Trust said: "We want to express our sincere condolences to Lila's family for their heartbreaking loss.

"It is clear from the independent investigation that there were missed opportunities in Lila's care. We accept the coroner's findings and apologise unreservedly for this.

“As a trust, we have made and will continue to make improvements to ensure we learn from this case."