Hospital Apologises ‘Unreservedly’ After Death of Disabled Girl

Published on: 4 Jun, 2025
Updated on: 5 Jun, 2025

The Royal Surrey County Hospital (RSCH)

The head of the Royal Surrey has apologised “unreservedly” after the death at the hospital of a 12-year-old disabled girl.

Rose Hartfleet died at the hospital on January 30, 2024, having attended its A&E department the day before with abdominal pain and vomiting.

Rose had been diagnosed since birth with a rare condition known as mosaic trisomy 17.

Following an inquest, a coroner’s report stated that when Rose was examined no history was taken at the hospital from her mother and that the severity of her signs and symptoms were underestimated. The coroner said Rose was “wholly reliant on her mother to advocate on her behalf”.

The report added: “This gives rise to a concern that by not listening to parents or guardians as a matter of course leads to discrimination of disabled children.”

Louise Stead, CEO RSCH

Louise Stead, chief executive of Royal Surrey NHS Foundation Trust, apologised to the family for the “failures in her care” and said she was “deeply sorry for their devastating experience”.

She added: “I appreciate that no words or actions can bring Rose back or reduce the grief felt by her loved ones.”

She said the trust had carried out a thorough investigation into Rose’s death. They had implemented several areas of learning and that practices would be further reviewed in light of the coroner’s recommendations.

The assistant coroner for Surrey, Karen Henderson, said in her recent report that there was a failure of the medical and nursing staff to appreciate Rose was clinically deteriorating. Poor clinical decisions contributed to Rose’s death.

Her report also raised concerns about a lack of national or local guidance to assist hospital staff to “appropriately manage patients such as Rose”.

The President of the Royal College of Emergency Medicine, Dr Adrian Boyle, said patients with learning disabilities – especially children – were a group at high risk of missed diagnosis and treatment.

He said the report was “heartbreaking to read” but that it was “vital” to examine what happened, “learn from it, and do all we can to prevent anything similar happening in the future”.

He added: “Everyone at RCEM extends our deepest sympathies and condolences to Rose’s family and friends.”

The college had been working to raise awareness, and to improve the quality of care patients with learning disabilities received while in the emergency department, he added.

An NHS spokesperson said it was “carefully considering” the coroner’s report.