Billie Wicks was taken to the Royal Free Hospital in September last year, but because she was not regularly observed at the “understaffed” hospital, the severity of her illness was not recognised, senior coroner Mary Hassell said.
Billie then died on September 15 after being “inappropriately discharged”.
In a prevention of future deaths report, Ms Hassell said: “Billie was inappropriately discharged at approximately 3.30am without adequate repeat observations or senior clinical review, and so her asthma was not diagnosed or treated.
“If it had been, she probably would have survived.”
Ms Hassell drew comparisons to the case of Daniel Klosi, aged 4, who died from sepsis at the same hospital in 2023.
Daniel Klosi, 4, died of sepsis after Royal Free Hospital staff told his parents he should go home and take Calpol (Image: Irwin Mitchell) Daniel had been taken to the hospital emergency department four times in the week before his death and at his inquest Ms Hassell raised similar concerns about observations.
“Although the circumstances were different, there is a theme,” she said.
A spokesperson for the Royal Free London said: “We would like to share our heartfelt condolences with Billie’s family and to say how sorry we are that she died while under our care.
“Following an investigation into the care provided to Billie, we have taken steps to increase staffing levels in the children’s emergency department during nights and weekends and improve the process for alerting senior clinicians when an abnormal test result is received.
“We will carefully review the coroner’s findings and respond to all the matters she has raised.”
