'Chaos, illness and crowds': 'Beautiful' three year old girl died of Strep A after leaving an 'overwhelmingly busy' hospital

Grieving mum Jemma Graham said she was surrounded by 'chaos, illness and crowds' when she made the decision to leave St Richard’s Hospital with 'exhausted' Penny Stevens. The decision came after a triage nurse and doctor had given an initial opinion that her daughter was probably suffering from a virus, a jury was told.

The inquest heard that the Chichester hospital, resembled a 'third world country' that day, having been inundated with 'worried' parents from Emsworth who had visited the paediatric department following a media alert about the bacterial infection.

Rather than wait in those conditions for a formal assessment, Ms Graham decided to take her daughter home, the hearing was told. The following morning, however, the youngster's condition hadn't improved and the family called 999 - but the ambulance took four hours to arrive. Penny was taken to Queen Alexandra Hospital in Portsmouth where she sadly died, the jury was told.

Ms Graham told the inquest at Winchester Coroner's Court that she will 'die with regret' that she took Penny to that department on the evening before her death.

The hearing was told Penny was taken to St Richard’s Hospital on December 3 2022 after suffering a chesty cough and low grade temperature for three days. Ms Graham said that upon arriving to the hospital, at just after 5pm, a receptionist told her that the computer 'system was down', so she had to manually record Penny's history and details. The mother said after doing so, she then entered the waiting room.

In her witness statement, she said: "I have never seen a waiting room so busy and noisy that I was taken aback. The room got busier and busier...louder and louder."

Ms Graham said there were children who were 'crying' and being held by their parents who had 'nowhere to sit'. The inquest heard Penny was seen for a triage assessment by nurse Helen Evison at 6.26pm.

Ms Graham said the nurse didn't have a thermometer at first, and when she 'finally found one', she recorded a temperature of 36 to 38 degrees Celsius. The mother said the nurse also didn't have a stethoscope, and asked a doctor who had entered the room to check Penny's chest. She said said this check was 'very brief' as he made 'one tap on each side of her back'.

The inquest heard the doctor told Ms Graham that there was no cracking or wheezing, and he believed her rash to be viral.

The mother said: "The nurse said 'Penny does have a virus so let’s give her some ibuprofen and see how she goes, but the rash is just a typical viral rash.

"[The] nursed asked if she could see walk, I put Penny down and she cried out to me."

Ms Graham said she told Ms Evison that Penny wouldn't be able to walk that as 'she was exhausted and we have been here a while'.

The mother was asked to take a urine sample of Penny, and said that after leaving the room she could see wheelchairs and trolleys lining the corridors. Ms Graham said Penny was growing 'distressed' in the hospital, adding: "The conditions were shocking and I made the decision to leave on the grounds they couldn’t help us.

"I felt surrounded by chaos, illness and crowds she was more at risk staying, and being there was making Penny distressed. I was familiar with the process of assessments and this was the worst one I’d ever seen.”

The inquest heard that at around 8.24pm that evening, a doctor called out Penny's name to assess her, but by this point had already left.

The following day, Penny's parents called 999 as the youngster's breathing had become fast and they knew she needed medical attention. Ms Graham said she was told by the service that a vehicle would be sent 'right away' - but said they ended up waiting for several hours before being taken to QA on December 4.

"I guess we will never know if we had drove her to hospital would we have saved Penny, but we will live with this for the rest of our lives," she said.

Ms Graham said soon after arriving, she heard a nurse say that they would need to 'start CPR' on her daughter. She said she waited in a room for an hour and a half while medical staff attempted to resuscitate young Penny. Sadly, the youngster passed away at QA, despite the best efforts of its 'heroic' and 'compassionate' staff.

In her statement, Ms Graham said: "I will die with the regret that I chose them (St Richard’s) as the place we took Penny that night.

"We believe it cost her life the following morning...

"My guilt is sealed within for the rest of my life and I can’t quite forgive those that should have helped us.

"I will do, as I need peace, but these images of what I saw at St Richards, now knowing my daughter was dying, will forever be imprinted and I can never forget”

Ms Evison, the nurse who saw Penny, gave evidence at the inquest and described the 'immense' pressure in the paediatric department the day Penny visited.

"It was a day like I have never had in my life,” she said. "We were utterly blindsided by the amount of patients that came through the department that day.

"It's a very small paediatric area, there was nowhere for patients to sit.

"There's no play area, nowhere to put prams pushchairs.

"There was no drinks fountain and it felt like being in a third world country that day.

"It was so overcrowded, there were people sitting on the floor.

"I have never seen anything like it and it did continue like that for the rest of the month."

The nurse told the inquest that the department was busy because of a 'media alert' about Strep A which prompted 'worried' parents to visit.

Ms Evison said she gave Penny ibuprofen and asked her mother to carry out a urine test so that she could be reassessed within an hour. She said she thought Penny presented as an 'unwell child'.

Dr Maggie Davies, the chief nurse at University Hospitals Sussex NHS Foundation Trust, said: "We are so sorry for the heartbreak suffered by Penny's family, and the terrible loss they have endured.

"As the inquest has heard, December 2022 was an extraordinary period with unprecedented numbers of poorly children needing care.

"We will give the coroner all the support we can throughout the inquest process, and continue to improve and strengthen patient care whenever we can."

The inquest continues.