Six-year-old ‘sent home to die’ after misdiagnosis – Inquest finds neglect contributed to death

Following a harrowing inquest, it has been formally concluded that neglect by North Middlesex Hospital NHS Trust contributed to Shen’iyah Green’s death.

The inquest, at North London Coroner’s Court, heard that Shen’iyah was taken to North Middlesex University Hospital A&E with symptoms including fever, vomiting, shortness of breath and pain in her right leg. Despite her sickle cell condition being clearly documented in her records and flagged repeatedly by her mother, Shanieka, medics diagnosed her with gastroenteritis and discharged her.

The coroner heard that the Trust made three critical admissions that contributed to Shen’iyah’s death - the omission to obtain a blood sample; the failure to document the cause of abdominal tenderness; and the failure to admit her to hospital. The cause of death was given as splenic sequestration—a rare but recognised complication of sickle cell disease. The inquest concluded that these failures amounted to neglect.

When Shen’iyah was diagnosed with gastroenteritis and sent home, medics did not consider the complexities of her sickle cell disease, despite this being clear in her records – Shen’iyah also had a ‘pink passport’, which immediately makes her condition obvious, and was highlighted by Shanieka throughout their hospital visit.

Shanieka, a mother-of-four and nurse practitioner, repeatedly asked medics to reassess her daughter and conduct more tests – but she was assured she was fine to be discharged home.

This was at around 5.25pm on January 11, 2019 – by 8pm, she had been pronounced dead, having fallen asleep on the car journey home and she never woke up. Shanieka tried desperately to give her daughter CPR, and paramedics attempted resuscitation for approximately an hour.

Shanieka – also mother to Marley, Zayne and Syenna Rose – has described how the family feel “lost” without Shen’iyah, and “struggle to deal with the manner of her death.”

“This was wholly avoidable. She was only six years old and deserved so much better than being sent home to die,” says Shanieka, from Enfield, who has been diagnosed with PTSD after the loss of her daughter.

“Shen’iyah had sickle cell disease, which meant she should be treated under specialist sickle cell protocols - but this did not happen, and she has paid the ultimate price. She did not receive the care she needed and deserved.

“I know my daughter better than anyone and I was not listened to. I asked for blood tests to be carried out, I asked for a second opinion, I repeatedly raised my concerns that something was badly wrong, but I was told she was fine to go home. She fell asleep on the car journey home and never woke up again.

“When Shen’iyah was rushed back to hospital, the same triage nurse and doctor were there who had seen her earlier that day. This made me very angry – why didn’t they listen to me earlier when I begged them to?”

A Serious Incident Report by North Middlesex Hospital NHS Trust highlighted that Shen’iyah’s observations “were not completely within normal limits and more information was needed” before discharging her.

Shen’iyah’s cause of death was given as splenic sequestration – where red blood cells become trapped in the spleen, causing enlargement and reduced blood volume – which the report acknowledged is a “rare diagnosis for a six-year-old child with sickle cell disease and therefore may not have been considered - but may have been picked up if the child was in hospital.”

Shanieka says she continues to be haunted by the fact she was not listened to by medics, and that her concerns for her daughter were dismissed.

“I do not want another family ever to go through an ordeal like this, to feel such unbearable pain, to be haunted by the memories of having to do CPR on your dying daughter, having been assured only shortly before that she was fine and well enough to go home,” says Shanieka.

“Families need to be listened to and their fears and concerns for their child taken seriously. Children must also receive the care that is right for them, particularly in cases where they have specific medical conditions which warrant specialist attention. There can be no excuses for Shen’iyah’s death – but we only hope that lessons are learned from it so this can never, ever happen to another child.”

Shanieka and her family are being represented by law firm Slater and Gordon in finding answers around Shen’iyah’s death.

“This is an absolutely horrendous case, where Shanieka’s very real fears for her daughter were dismissed and less than three hours later her daughter was dead. There are serious issues for North Middlesex Hospital to consider around the care Shen’iyah received, and why she was not treated under specific sickle cell protocols,” says Madeline Seibert, technical director at Slater and Gordon.

“Time and again, we hear cases of families’ concerns not being taken seriously by medical professionals – but families know their loved ones best, and they deserve to be listened to. The loss of Shen’iyah is something her family will never come to terms with, and particularly the fact that her mother tried to fight on her behalf but was overruled.”