Manchester Evening News
Emma Stones, 12, died after doctors failed to carry out routine blood tests because they were too busy, an inquest was told.
Emma was admitted to Tameside General Hospital in Greater Manchester with flu-like symptoms but contracted a bacterial infection which led to septicaemia.
She died from the blood poisoning 16 hours after she was admitted to the hospital.
The inquest heard how there was a catalogue of errors in the lead-up to her death.
Coroner John Pollard criticised the lack of urgency and co-ordination in her care, but he said he could not be sure that earlier intervention would have saved her.
The hearing was told:
Emma's blood pressure was never taken as it should have been under hospital policy;
A junior doctor wanted to take a blood sample but a senior registrar was too busy to help;
A team of three nurses failed to regularly monitor her throughout the night - she should have been observed every four hours;
One nurse was suspended as a result and later received a warning after an internal disciplinary hearing;
Two other nurses will now be made subject of extra training in observations
A series of policy changes have been implemented at the hospital as a result of Emma's death.
Mr Pollard said the issues amounted to 'inertia' on the part of staff.
Manchester Evening News
Emma, a pupil at Cromwell High in Tameside, was diagnosed with cerebral palsy at birth. She leaves behind her twin sister, Christina, and parents Mike Stones and Tracey Futcher.
Doctors said she was stable before her condition deteriorated without warning.
Emma, who suffered health problems throughout her life, was taken to hospital on the advice of community nurses on Sunday, February 6 2011.
The hearing was told how junior doctor Dr Kayleigh Hughes wanted to take a sample of her blood and asked for help.
But a senior registrar was too busy to carry out the test due to his workload, the inquest heard.
There was nothing to indicate that Emma was seriously ill, but her heart rate increased five hours after her admission.
The inquest was also told that key information about what treatment Emma might have needed was not included on a handover note when staff changed shifts.
Emma's condition deteriorated and she had a heart attack at around 8.15am the following Monday morning.
Tests ruled she contracted an infection, group A streptococcus, which led to septicaemia, or blood poisoning. If untreated, it develops into septic shock, where blood pressure drops and organs fail.
Children's services matron Wendy Hulse said changes to nursing policies had been made.
The inquest heard that doctors' notes will now be reviewed with regard to their content, not just their dating and signing.
Detailed changes to staff shift handover arrangements are also being made.
Philip Dylak, director of nursing at Tameside Hospital NHS Foundation Trust, said: 'While it would not be appropriate for the hospital to comment on the details until the coroner has reached his verdict, we would wish to express our deepest sympathies to the family of Emma Stones at this very difficult time.'
The inquest will resume on March 6, where Mr Pollard is due to reveal his findings.