An NHS Trust has acknowledged its severe failures in the death of three-year-old Zadie Ajetunmobi, who died after sepsis went undiagnosed. Despite showing signs of the infection, such as a high temperature and rapid heart rate, doctors at Broomfield Hospital in Chelmsford misdiagnosed her with tonsillitis and delayed administering intravenous antibiotics for over seven hours, resulting in a fatal cardiac arrest.
The Mid and South Essex NHS Foundation Trust admitted that adhering to sepsis guidelines could have saved little Ajetunmobi’s life, according to Daily Mail. At her inquest in Chelmsford Coroner’s Court, the Trust’s lawyers expressed deep remorse to her father, Theo, for the series of fatal mistakes made in November 2022.
During the hearing, the Trust’s letter of admission revealed that an internal investigation found medics failed to recognize the severity of Ajetunmobi’s condition. The Trust acknowledged delays in treatment and admitted that the sepsis pathway was not followed.
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“Had the sepsis pathway been triggered at triage, intravenous antibiotics would have been administered to Zadie within an hour. Had intravenous antibiotics been administered in an hour, along with other supportive care…Zadie would not have suffered a cardiac arrest when she did and would have survived,” the letter said.
The Trust also identified key failings, including incorrect assessment of the child’s early warning tool (CWT) score and insufficient review by a senior clinician in the A&E department. It acknowledged that the results were “absolutely tragic”, adding: “Those at the Trust deeply regret the failures that took place and are extremely sorry.”
The inquest revealed that a doctor did not see Ajetunmobi for over three hours after arriving at A&E on November 10, 2022. Despite her heart rate exceeding 180 bpm and her temperature reaching 40°C, staff failed to raise the alarm.
Expert witness Dr. James Gray testified that Ajetunmobi likely had Strep A and that her vitals should have activated the sepsis pathway.
“There was a clinical picture that Zadie’s condition had deteriorated…but for reasons, that are not for me to comment on, she neither received antibiotics or the level of support that I would have expected by the blood results and Zadie’s condition in terms of physiological measurements taken at triage.
“I would have expected that Zadie would have entered the sepsis pathway and she would have received the full sepsis bundle,” which he said includes antibiotics, intravenous fluids and close monitoring.
Expert testimony revealed that despite clear signs of infection, antibiotics were not administered to Ajetunmobi until after 5 a.m., two hours before her death.
Dr. David Sanwu, a junior doctor who assessed her at 1 a.m., admitted he did not suspect sepsis as she did not appear extremely unwell.
However, he said that he had not been familiar with the national sepsis guidance adding: “This particular tool at that stage I had never used.”
He concluded his evidence by apologizing to the family saying: “This is the worst case I’ve been involved with in my medical career and is one which will stay with me.”
During the inquest, Ajetunmobi’s mother, Rhiannon, provided heartbreaking testimony. She recounted taking Ajetunmobi to the hospital while her husband stayed home with their son. Rhiannon described how Ajetunmobi’s, suffering from a sore throat and high temperature, suddenly deteriorated after being moved to the pediatric ward, where she was given antibiotics by injection.
“I noticed her breathing started to sound raspy and I informed the nurse… and her heart was beating very quickly,” she added.
She testified that her daughter was given a nebulizer, which seemed ineffective, and a nurse provided her with a syringe of paracetamol.
“I tried to give it to her but she suddenly went floppy… and I screamed,” she said before a nurse set off the alarm and the room was overrun with medics.
“My mind went blurry at this point, I was unable to focus on what was going around me… the next thing I remember is being informed that Zadie had passed,” the devastated mother said.
Theo Ajetunmobi, 42, recounted speaking to his usual bubbly toddler just hours before her death during a video call.
“We gave each other a thumbs up. I asked her to smile and she flashed a micro smile which faded quickly,” he said.
“She made our family whole, she was cherished and loved and brought so much joy…Words cannot express the depth of loss we feel as a family.’
Theo Ajetunmobi stated that the pain of losing his daughter was intensified by the fact that her death was “needless.” He added that if the correct procedures had been followed, she would still be alive.
