Lila Marsland: Prevention of Future Deaths Report

1) The Chief Executive, Tameside and Glossop Integrated Care NHS Foundation Trust 
2) The Secretary of State for Health and Social Care 

I am Chris Morris, Area Coroner for Greater Manchester South. 

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.  http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 

On 30^th October 2024, Alison Mutch OBE, Senior Coroner for Greater Manchester (South) opened an inquest into the death of Lila Airelle Marsland who died at home on 28^th December 2023, aged 5  years. The investigation concluded with an inquest which was heard between 27^th May to 5^th June  2025 before a jury. 

A post mortem examination determined Lila died as a consequence of Pneumococcal Meningitis  (Streptococcus Pneumoniae). 

At the end of the inquest, the jury returned the following Narrative Conclusion: 

‘Lila Airelle Marsland died as a consequence of undiagnosed and therefore untreated Pneumococcal Meningitis (Streptococcus Pneumoniae) a number of hours following her  discharge from hospital. Lila’s death was contributed to by neglect.’ 

Lila Marsland was brought to Tameside General Hospital on 27^th December 2023, having become  unwell that day with symptoms of headache, fever, lethargy and neck pain. Following interaction  over the hours which followed with a range of healthcare professionals, Lila was discharged home  with a diagnosis of viral tonsillitis and a prescription of oral antibiotics and a throat spray. Lila was  found to have died around six and a half hours after her discharge from hospital.  

To the Chief Executive, Tameside and Glossop Integrated Care NHS Foundation Trust
 
1. Having carefully considered the oral evidence given in court by a range of different clinicians with varying roles and remits, I am concerned that, notwithstanding the work the Trust has  undertaken in response to Lila’s death, the Child Sepsis Screening Tool is not yet fully  embedded in the minds of those who assess and treat Children and Young People at the  Trust;  
 
2. I am concerned that the Trust is yet to fully implement the latest iteration of the National  Institute of Health and Care Excellence’s Guideline Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management (NG240 Published 19 March 2024); 
 
3. It is a matter of concern that the Locum Consultant in Emergency Medicine who completed a form indicating Lila was ‘Safe to Transfer’ to the Paediatric Emergency Department did so  without undertaking any examination or direct assessment of her. The doctor had 
previously filed a statement at court indicating he had undertaken a ‘preliminary visual  assessment’ of Lila, but accepted in oral evidence that this was not, in fact, the case;  
 
4. I am concerned that no medical record appears to exist of the examination of Lila which was undertaken by the Locum Registrar in Paediatrics which resulted was discharged from  hospital. The absence of this key piece of evidence serves to limit the ability of the Trust to  derive all possible learning from Lila’s death. 

To the Secretary of State for Health and Social Care 

The court heard evidence that, over the course of almost 10 hours in hospital, Lila’s history and  details of examinations and assessments undertaken were recorded on a mixture of various  analogue and digital systems in operation in different parts of the Trust, leading to a risk of vital  clinical information being lost in the system. 

I am concerned that this, and other hospitals elsewhere in the country, continue to operate with information being stored and shared between professionals in a fragmented and disjointed way.

In my opinion action should be taken to prevent future deaths and I believe you and your  organisation have the power to take such action.   

You are under a duty to respond to this report within 56 days of the date of this report, namely by 6^th August 2025. I, the coroner, may extend the period.  

Your response must contain details of action taken or proposed to be taken, setting out the  timetable for action. Otherwise you must explain why no action is proposed. 

I have sent a copy of my report to the Chief Coroner, together with the family and the Trust’s legal representatives.  

I have also sent a copy to the Care Quality Commission and the General Medical Council, who may  find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your  response.   
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may  make representations to me, the coroner, at the time of your response, about the release or the  publication of your response by the Chief Coroner.  

Signature:    Chris Morris, Area Coroner, Manchester South.