THE Essex coronor has delivered a damning review of Basildon Hospital after a 'young and fit' teenage girl suddenly died following a 'serious failure' of procedure there - though the Trust that runs the hospital has rebutted his concerns.

Millie Hook, 19, a trainee teacher from Benfleet working at Thundersley Primary School, died after suffering a cardiac arrest at the hospital on January 28, 2024.

In a prevention of future deaths report, coroner Stephen Simblet says Millieprobably would have survived' a severe illness had she been given "appropriate and necessary medical treatment" at the hospital's emergency department.

Mr Simblet added concerns that systems for dealing with "clearly unwell" patients at the emergency department at Basildon Hospital are "inadequate."

Millie, described by the coroner as a "comparatively young and fit patient" died at Basildon hospital having suffered a cardiac arrest while awaiting further care in the hospital.

She had suffered a bout of ill-health at home from a viral-type of illness with diarrhoea and vomiting. An ambulance was called and crews immediately realised that she was seriously unwell and needed to go to hospital.

She deteriorated so quickly during her journey to hospital that paramedics considered that she needed immediate attention to 'what looked like a serious case of sepsis.' However, delays in admitting her to hospital caused her to continue to deteriorate, Mr Simblet's prevention of future deaths report said.

Even after being admitted, she did not receive her catheter until many hours later nor were blood measurements monitored or acted upon with "any degree of immediacy or sufficient appreciation of the seriousness of Millie's condition". Millie was not transferred to the critical care unit (CCU) at any point, despite her continuing to deteriorate and becoming increasingly unwell, Simblet added.

Mr Simblett said in the prevention of future deaths report: "Throughout her stay in hospital, the deceased was inadequately monitored, with readings of these measurements being inadequately recorded and insufficient attention paid to the implication of those measurements. Overall, the severity of the deceased's illness and its continuing worsening despite the interventions of these treatments were not sufficiently appreciated.

"Even though at some stage the doctor treating her in the emergency department considered that the deceased should be transferred to the CCU, the deceased was not transferred, in part due to a conflict between the hospital departments as to whether this very unwell patient met the criteria to be in CCU, but in any event, the failure to transfer the deceased either immediately, or within a period of around an hour after her arrival at the hospital, was a serious failure to provide her with appropriate and necessary medical treatment.

"Had the deceased received such treatment, she would, on the balance of probabilities, have survived."

At around 12.45am, Millie went into cardiac arrest, from which resuscitation efforts were unsuccessful. She died at 1.45am on January 28, 2024 in the resuscitation area of the hospital. The conclusions of the inquest consisted of judgmental narrative findings, and a conclusion of death by natural causes contributed to by neglect.

Mr Simblet warned there is a risk that future deaths could occur unless action is taken – citing concerns that the systems for dealing with patients in the Emergency Department at Basildon Hospital are "inadequate" and that cases are "not being appropriately escalated to senior clinicians in a timely manner".

He also had concerns about the standard of clinical expertise in not just in the emergency department at Basildon but across the whole Mid and South Essex NHS Trust – which include Broomfield in Chelmsford and Southend hospitals.

He added: "There is a concern that those working in substantive consultancy posts at Basildon Hospital and other hospitals in the trust, including in departments to which critically ill patients may be taken and where the care that such patients receive might affect whether they survive or not, do not hold the appropriate consultant registration standard and that the continued employment of such consultants on a long-term basis does not meet the appropriate NHS standards for holding and maintaining employment in such positions."

In a lengthy response to the prevention of future Mid and South Essex NHS Trust has rebutted the concerns around standards, though Denise Townsend, interim chief nursing officer at Mid and South Essex NHS Foundation Trust, said: "Millie's death affected us all greatly and we offer our sincere condolences to her family."

The Trust's formal response said: "Our chief medical officer has provided assurance that the trust only employs suitably qualified doctors holding specialist registration to substantive permanent consultant posts. In circumstances where the consultant vacancy cannot be filled by a consultant on the specialist register, or the trust has a temporary gap, (for example due to a sabbatical or maternity leave), we may appoint a locum or fixed term consultant without specialist registration in line with national guidance.

"In Millie's case, one of the critical care consultants who was involved in her care had the following qualifications and designation as detailed; MBBCh, MSc, EDIC, FFICM, EDEC, Locum Consultant in Intensive Care Medicine. This doctor was appointed in 2023 through a competitive process and has both European and UK Fellowship qualifications in intensive care medicine.

"The annual appraisal process for locum consultants who are not on the specialist register is the same process as for substantive consultants and provides assurance to the trust's responsible officer and the General Medical Council (GMC) that the doctor remains up to date and fit to practice.

"Locum consultants are entitled to supporting professional activity, training, and continuing professional development time and funding in the same way as substantive consultants. Locum consultants within the trust have an annual job plan agreed with their clinical director which defines their scope of practice inline with their skills and qualifications."

The trust added that the deputy director of nursing for Basildon Hospital has confirmed that, since this incident, detailed reviews of the medical and nursing skill mix in the emergency department have led to funded staffing increases in both workforces, strengthening the team's clinical capacity.

This has included two additional senior doctor posts, plus a significant increase of 27 registered nurses – allowing five per shift – and 22 health care assistants – four per shift. It said that whilst recruitment is underway these places are successfully filled with temporary staffing options "with an ever-decreasing vacancy rate".

It said the trust has also introduced a revised ED specific policy which "focuses on ensuring the safe management of patients attending the emergency department, defining clinical ownership within the department and sets out the appropriate escalation routes."

Millie's dad, Robert Hook, said her life had been tragically cut short just as it was "taking off".

He said she was "greatly missed" by family and friends who remembered her as a young woman with a "passion for helping people".

He said: "Millie was a kind and happy 19-year-old girl.

"She was much loved by her family and friends.

"She was ambitious and had a passion for helping people, she was training to be a teacher."

As well as the apology and expression of sympathy, Ms Townsend's statement also said: "We investigated the circumstances behind her death with all departments involved in her care.

"We identified areas for improvement, including faster escalation for specialist reviews and more frequent monitoring of deteriorating patients.

"Lessons have been learned and shared with all the clinical teams involved in Millie's care.

"We have strengthened our governance processes and changed our operating structure to ensure senior clinicians have greater oversight of patient care and that concerns are escalated promptly."