Makenna-Rose Thackray was taken to Pinderfields Hospital in Wakefield by ambulance two days before her death in December 2022, but went home after a six-hour wait in A&E. She was taken to see her GP the following day, but was sent home without antibiotics.

At her inquest, it was found that opportunities to potentially save Makenna-Rose were missed through her not being observed when she went to Pinderfields, due to the hospital being “significantly busier than normal”.

The jury also found that her GP’s advice “would have been different” if they had known about her hospital trip, and the fact she had previously been vomiting blood – neither of which were communicated.

Makenna-Rose was diagnosed with scarlet fever, caused by Strep A, on December 9, 2022. Nine days later, on December 18, she attended Pinderfields A&E during what was described as “one of the worst” shifts the staff had seen, with two nurses left to deal with almost 80 children – around double the number who could be safely treated.

The inquest said she was not seen by medics after being given a paediatric advanced warning score (PAWS) of seven – this should have been done within 20 minutes of arriving – and observations should have continued every hour. She also should have been given a blood test.

After an extensive wait with no medical attention, her family took her home, and visited their GP the following day, who unfortunately was not made aware of the background to her visit. Makenna-Rose died the following day, on December 20, after she stopped breathing and went into cardiac arrest.

Mid Yorkshire Teaching NHS Trust, which manages Pinderfields – which is rated by CQC as requiring improvement - said it will “take every opportunity to learn from missed opportunities”.

Jodie Cook, senior associate in our clinical negligence team, stressed the urgency of Pinderfields and the wider Trust learning from this case.

“Makenna-Rose’s death is an absolute tragedy, not least because of the missed opportunities to intervene and potentially save her life. It is devastating to know that had she been properly assessed, or even if accurate information had been communicated to her GP, she could still be here today,” says Jodie.

“The Trust have said that they will learn lessons, but for these words to have any meaning, it is absolutely imperative that they do so. Action must be taken without delay to ensure this cannot happen again.

“The fact that Makenna-Rose was left for six hours without proper checks being made is wholly unacceptable – the Trust need to make sure that staff are properly supported and critical facilities like A&E are adequately resourced so that we do not see a repeat of this horrific situation.

“Families and patients also need to feel confident that their medical records relay crucial information, so that treating professionals can make informed decisions. If Makenna-Rose’s GP had known the full picture, again the situation could have been so different. This is another urgent action that we need to see addressed, with appropriate action taken by the Trust.

“The devastation Makenna-Rose’s family will feel is beyond words – the Trust owe it to them to take all necessary steps to ensure others do not find themselves in this situation.”