Justice For Coco Rose Bradford

*** UPDATED FRIDAY 18TH FEBRUARY***
My name is Rachel Bradford and I am Coco's mum. Coco died in 2017 as a result of clinical negligence. She was just 6 years old.  Coco had Autism.
Coco's death was investigated and as a result an inquest has been opened and will commence on Monday 29th November 2021, over  four years after her death.
We have a new legal team including solicitors from Barcan and Kirby and a QC, Lorna Skinner who has offered her services pro bona.
The inquest is scheduled for 8 days. (A standard inquest lasts 1-2 hours) This is expensive and it is money we don't have. We can't cancel an inquest and we have no choice. Coco's case could possibly qualify for a breach of The Human Rights Act,  Article 2 - The Right to Life and also Gross Negligence Manslaughter. We could choose not to attend but that would never be an option for us and having seen reports that medical staff have blamed Coco, and at times her Autism, for their failures we are more determined than ever to raise the funds for representation. The hospital have unlimited resources to legal representation and that's just not fair. This campaign is to ensure that Coco gets the justice she deserves. When Coco's inquest is over we will fight for legal aid to be available in all cases where clinical negligence is a factor. Coco was the most precious little person in my life and I never, ever want anyone else to have to go through this process.  We are trying to raise £20,000 but in reality it will probably be double that amount but we will do anything we can to raise the rest. Please help in any way you can, donating or sharing on social media, tell your family, your friends, anyone you can.

Coco's sister Chelsea has put together a video for you and the song was provided by Molly Hocking - Winner of The Voice - in memory of Coco. Thank you xx

IF YOU WANT TO READ THE LETTER I WROTE TO CORONER AFTER THE CONCLUSION YOU CAN READ IT HERE: 


Dear Mr Cox,

Coco Rose Bradford Inquest

I write this letter with the utmost respect for you in your position as the Senior Coroner for Cornwall & The Isles of Scilly and the difficult circumstances that surround you on a daily basis. I understand that Coco’s Inquest was particularly difficult given the length of time since she died and the number of people involved. My family and I would like to thank you for your understanding at, what was and still is, a very difficult time. I felt compelled to write to you as we have, following Coco’s Inquest, been left with more questions than answers and that, simply put, is unacceptable.
In 2019 you asked me directly to put my trust in the system, I was sceptical, and rightly so. 
Since Coco died and up until that time it had been a particularly difficult time dealing with a hospital that had no interest in helping me seek the truth in what happened to Coco. 
I have no need to remind you of the Facere Melius report, its findings and recommendations all of which were accepted, in full, by RCHT and at the time it was the closest to the truth we were ever going to get.
I also have no need to remind you of all the failings that were highlighted at the inquest and the fact, up until Day 6, that Coco had Sepsis. So I find it impossible to believe that a hospital, the clinicians involved and the Trust that accepted and treated Coco for overwhelming Sepsis, agree that Coco did not, in fact, have Sepsis. When was this agreed and accepted, and why were we not informed?
I think I am right in assuming this was based on culture negative blood results, received after Coco died.
As I am sure you are aware, just under 50% of blood cultures return culture negative for Sepsis, when the patient does in fact have Sepsis. This is why clinicians rely on the patient and their observations for a more accurate picture. If they waited for the results of blood cultures 49% of patients with Sepsis would probably die! 
The most important factor associated with negative cultures is receipt of antibiotics during the preceding 48 hours. Negative cultures should not give the clinician a false sense of reassurance - patients are still at risk of death, with the risks being dependent on severity of the physiologic derangements before and on the day of sepsis. 
Sepsis can affect multiple organs, primarily the kidneys, or the entire body, even without blood poisoning or Septicaemia. 
Here’s the thing,  RCHT and probably every qualified clinician in the world are well aware of these statistics and the ‘unreliability’ of blood cultures and let’s be honest here, Coco had all amber flags and 5/6 red flags for Sepsis on Wednesday and now we are to believe that all those flags were due to the onset of HUS and of course Dr Hopkins is to be commended for this observation as a secondary diagnosis on Wednesday. (not forgetting that not one person acted upon this diagnosis) but I digress. 
Sepsis and HUS do present in a very similar way, in blood results and in presentation but they are not the same, so when you stated in your summing up that “as a matter of fact Coco did not have Sepsis” and “unfortunately the family were misled” I would like to put it to you that as a matter of fact and on the balance of probabilities Coco DID have Sepsis and we were not unfortunately misled we were deliberately misled. I completely understand the conclusion you arrived at was based on the facts that were presented, I believe those facts were not entirely accurate.
Now this will probably not be classed as new evidence but I would appreciate your assistance on the basis of my family being misled regarding Sepsis and had we known that apparently Coco did not have Sepsis prior to the Inquest we would have been prepared to present the following findings as fact.
As I mentioned earlier Sepsis and HUS are very similar in presentation except for a few very important differences. 
Simply put, Sepsis causes blood pressure to plummet and HUS causes it to rise. Sepsis results in cold peripherals and HUS results in warm peripherals and oedema. Coco had the former in both instances on Wednesday. These are just 2 basic but none the less extremely important differences. We can go further with the red blood cell count/haemoglobin. It rises significantly with Sepsis but drops with HUS. Coco’s Hb was 175 (Norm 96-148) on Wednesday, again indicative of Sepsis. 
Also on the pathology reports BO317-BO318 you will notice a note on Blood Film regarding the left shift of Neutrophils, toxic granulation and vacuolation. 
Toxic vacuolation is associated with Sepsis, particularly when accompanied by toxic granulation. 
When you fail to treat a clinically dehydrated child with an infection like E.coli 0157 with appropriate fluid management you are leaving the child open to the development of Sepsis. Leave both of these untreated and HUS is almost a given. Leave all of those untreated and the child will develop Septic shock and we can see from Coco’s blood results this is exactly what happened on Thursday evening. 
Coco arrived at Treliske early on Tuesday morning, she had multiple episodes of D & V, was dehydrated, not tolerating a fluid challenge, partially verbal, concerned parents telling staff there was blood in her faeces, yet she was sent home and not admitted or rehydrated for a further 36 hours, and even then not adequately, zero pain score, not transferred despite the suggestion of HUS, and this is not neglect? Did not contribute to her death?
Coco was handed over to Bristol PICU with a working diagnoses of E.Coli Sepsis, Septic Shock, HUS and persistent metabolic acidosis. Was that also a clerical error? 

E.coli 0157 H7 has a very high survival rate. Only 15%  develop HUS and of those 95-97% survive. Statistically those that die are babies or elderly. Where’s the balance of probabilities now? What gave Dr Tse the right to say that he “thinks” Coco was always going to die? A man that admitted he had no specialist interest in HUS yet was prepared to state on oath that Coco’s HUS was far too advanced and that the outcome would have been no different. 

HUS ‘potential’ diagnosis Thursday 11pm-1am. 6 days after Coco’s first symptoms. HUS was not so far advanced on Tuesday, in this case, that the outcome would have been no different. There are multiple studies and papers supporting early aggressive fluid management for E.coli and to support nephroprotection to prevent the development of HUS.

Let’s also not forget that HUS is not an infection it is a triad, classically of microangiopathic haemolytic anaemia, thrombocytopenia and acute kidney injury and is just as important to deal with these symptoms promptly rather than “eventually”

 

Tse mentions he thought Coco was at 'higher risk of death on presentation' If she was admitted 36 hours earlier like you, yourself, suggested Coco should have been, would that not have presented the opportunity to commence IV fluids much sooner thus preventing the risk factor element occurring? Something Tse suggests would have been less of a risk, if she had have been better hydrated on the 26th. 
RCH has no PICU or facilities for dialysis, you mentioned Hopkins early recognition of the possibility of HUS but then nothing was done to prepare for that eventuality, why not? I can see no evidence in cases of HUS where you can afford to leave a child unsupported and not accurately managed. Fluids, blood pressure and closely monitoring all observations are very much part of this, all of which have been evidenced as areas of failings during Coco's  inquest. 

Tse lists what 'a sick child with HUS needs is specialist paediatric anaesthetists, paediatric dialysis staff, paediatric dieticians other sub specialists such as a gastroenterologist and neurologists amongst others' most, if not all, were not available to Coco at RCH and only available on her late transfer to Bristol by which time we will all accept she was extremely poorly. 
This is added to the fact that her weight and fluid losses were never calculated accurately. How can all of these factors and more not have contributed to, on a balance of probability, the cause of death?

Let’s not forget all of the clerical and prescription errors that unfolded. All of which could have made some contribution to Coco’s death.

·      Nephrotoxic drugs that can contribute to Kidney Injury (or worse) – Ranitidine (Wednesday), Omeprazole(Thursday) 

·      Opiates ( like Morphine) and Chloral Hydrate also contraindicated in gastrointestinal illness.

·      Allergic reaction from a drug then re-administered. B0080 Never event not reported. Not a clerical error (none on unit) as clearly re-administered at 7.00am after Allergic reaction noted.

             The explanation from RCHT via Bevan Britten is simply not acceptable. 

·      Microbiology report from Southmead stating overwhelming Sepsis – a clerical error? 

·      Weight gain of 3kg – Coco was not weighed. She did not gain 3kg in Treliske.  There is simply no evidence to support this. We maintain Coco was not weighed and did not gain 3kg as a matter of clinical and medical impossibility due to losses and insufficient IV fluids. 

·      Weight recorded on transfer to Bristol as 16kg.

·      Clinicians were unsure if Coco was an HDU patient. BOO78 - Coco is ‘transferred’ to HDU between 22.00 (26/7) and 6.00 (27/7) - No confusion. 

 

I fought for over 4 years for the truth and we still do not have the truth. I feel extremely let down, I am sad, I am angry and I feel like I have let Coco down. I felt compelled to write to you personally as I am unsure what the next step should be but I can no longer afford legal representation and can not afford to instruct an independent Nephrologist or Microbiologist. I understand this is probably completely against all sorts of protocol but having been ‘misled’ for over 4 years I really had no other choice.

 

Kindest Regards

Rachel Bradford 

 

 
If you want to read the report into Coco's death you can find it here :
https://doclibrary-rcht.cornwall.nhs.uk/DocumentsLibrary/RoyalCornwallHospitalsTrust/ChiefExecutive/TrustBoard/Minutes/1819/201810Ex/IndependantInvestigation.pdf
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