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The lack of knowledge and attention at a hospital were factors that led to the death of a two-year old girl who had a rare response to influenza, an investigation has found.
Cristina Banciu died just a month away from her third birthday at King's College Hospital in South London.
A corona ruled that the two-year-old would have had a better chance of survival if she had been transferred to intensive care sooner.
The inquest heard that the girl had been flagged "multiple times" as a patient of concern at Princess Royal University Hospital.
It was found that there was a clear failure to monitor Cristina on the ward, detect her declining neurological condition and act on her low Glasgow Coma Score (GCS).
Assistant coroner Jacqueline Devonish said the failure to record Cristiana’s GCS was “very serious indeed”.
She said: “It seemed to me that there was a lack of attention and a lack of knowledge which had directly contributed to this little girl’s death.”
Ms Devonish said she is of the view that healthcare professionals “failed to provide basic medical attention”.
“In my view that’s a gross failure,” she said.
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But she said the law does not support a finding of neglect because there is no evidence that Cristiana would have survived had she been treated sooner.
In her narrative conclusion, Ms Devonish said: “Baby Cristiana died from a rare response to influenza in circumstances where the decline in her responsiveness, Glasgow Coma Score (GCS) of 8, and progressively sluggish pupils had not been recognised.
“It is not possible to say on the balance of probabilities whether she would have survived if transferred sooner.
“But she would, probably, have had a better chance.”
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Addressing the family, Ms Devonish said: “I’ve seen the picture of baby Cristiana on your T-shirt. She’s absolutely beautiful."
She said there had been “a catalogue of errors”, adding: “The tragic loss of this cheerful, resilient, beautiful, bright little angel is absolutely devastating for us all.”
The inquest heard the parents travelled with their daughter in the ambulance to King’s College Hospital and Mr Banciu said that was the first time he had been told of the “real situation” she was in.
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Mrs Banciu said that on arrival at King’s College Hospital the staff “did all they could” but that they were told their daughter had a less than 0.1% chance of survival.
Speaking after the inquest, Cristiana’s parents Alexandru and Georgina said: “Losing our daughter in such a horrific way has left us feeling like we have no reason to wake up in the morning.
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“She was the apple of our eye and her avoidable death has left us beyond devastated.
“The doctors and nurses who failed her need to face some sort of justice as without their mistakes our daughter may well still be here today."
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