The Coroner was satisfied Hayley Fullerton should have been referred to the paediatric unit on the 9th and that doctors should have realised that was the case. Hayley would have had a better chance of recovery if she'd been referred to the unit, the Coroner added.
The Coroner said failures by the hospital did not constitute gross failure as it was not up to the court to decide negligence.
The Coroner said there were failures:
.1. Failure to question why Hayley continued to need oxygen. 2. Failure to arrange follow up chest X-ray prior to 9th. 3. Failure to review x-ray. 4. Failure to conduct physiotherapy on the 9th. 5. Failure to refer to Paediatric Intensive Care unit. 6. Failure of PEWS assessment. 7. Failure to demonstrate to family that their concerns were being listened to. 8. Failure to explain decision to put Hayley in isolation.
The Coroner was "very very sad to find failures in Birmingham Children's Hospital".