'Missed opportunities' before toddler's death

An inquest has heard how there was a "catastrophic failure of documentation" by hospital staff before a 14-month-old girl died from inflammation of the heart muscle.

Viviana-Ray Butnaru died from myocarditis at Basildon Hospital, Essex, on 25 October 2024, the day after she was admitted with difficulty breathing.

Essex Coroner's Court heard a doctor ordered an X-ray and later mentioned myocarditis verbally in his handover to another doctor, but he had not documented it in the patient's records.

The coroner recorded a narrative verdict.

An investigation by Mid and South Essex NHS Foundation Trust found there had been missed opportunities to fully document Viviana-Ray's care and to act on the findings of the X-ray and blood gas tests.

The barrister representing Viviana-Ray's family, Darragh Coffey, described the series of failures by doctors and nurses to record findings or observations about the toddler over the course of her hospital stay as "catastrophic".

The inquest was told if Dr Ibriak Mohamed's suspicions about myocarditis or cardiomegaly (an enlarged heart) had been documented and acted upon sooner, an echocardiogram or ECG (electrocardiogram) could have been carried out, which may have determined the course of further treatment.

Jyoti Gill, the assistant coroner for Essex, said she would write a prevention of future deaths report about record-keeping as well as a lack of guidelines around assessing patients for heart conditions.

She said she would also look into awareness of parvovirus, which had seen a "surge" in the number of cases since the Covid-19 pandemic and disproportionately affects young children and toddlers, and which contributed to Viviana-Ray's myocarditis.

The coroner's report will be sent to the head of Basildon Hospital, the Care Quality Commission and the Royal College of Paediatrics and Child Health.

Recording the narrative verdict, Gill gave Viviana-Ray's cause of death as complications from myocarditis caused by parvovirus, contributed to by bronchiolitis and bronchial pneumonia.

She concluded that while there were failures in Viviana-Ray's treatment, they were "not directly causative to her death".

Viviana-Ray's mother, Larhys Skidmore, welcomed the coroner's findings.

"It's never going to bring her back, but she's not gone in vain. Her name isn't forgotten as somebody that just died of natural causes," she said.

"There's a lot of things that contributed, and a lot of mistakes made.

"I want it to prevent another child going through this and another family going through what we've been through, and I do think this is going to do that."

Sharon McNally, chief nursing officer at the NHS trust, offered condolences to Viviana-Ray's family.

"Following her tragic sudden death, we carried out a full investigation and have taken action to ensure that our resulting learning can demonstrate improvements in our care," she said.

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