Chloe Longster inquest - ‘During Chloe’s last 18 hours on this earth she was in pain and treated with contempt'

Chloe Longster had been a healthy, fun-loving teen until she was admitted to KGH with pneumonia in November 2022.

She died 18-hours later after developing sepsis.

At the first day of a week-long inquest today (Monday, October 7), her mum Louise Longster told a coroner that she had repeatedly asked medics for help but said she had been treated as though she was ‘mum who had been on google’.

Coroner Sophie Lomas heard Chloe had mild asthma and used inhalers but had never had an asthma attack.

Giving evidence, Mrs Longster said: "She was incredibly healthy.

"She only used the inhaler very rarely.”

On the weekend before she died Chloe, from Market Harborough, had been sniffly and had a cough but had been well enough to attend a sleepover.

Then on Monday, November 28, Chloe did not feel well enough to go to school so her mum left her elder brother, then aged 17, at home with her and went to work with instructions to call her if anything changed.

But at 11.15am Chloe phoned her mum to say her ribs hurt and she’d been sick.

"I phoned my husband and asked him to go back to her,” said Mrs Longster.

“He went back and said he could see she was uncomfortable but it didn’t seem like it was horrendous,” she said.

Mrs Longster then also decided to go home and see her daughter.

"I could see she was becoming more and more uncomfortable and panicked about the pain," she told the inquest.

Mrs Longster was asked by the coroner if this was unusual for Chloe.

“Yes,” she said. “She liked to go out to dancing, she liked to live and being ill was massively inconvenient for her. It was very out of character.”

She couldn’t get through to the GP and phoned 999 to be told an ambulance would take two hours. So Mrs Longster, her son and Chloe went to Kettering General Hospital by car.

"She was frightened,” said Mrs Longster.

"She was holding my hand, she was squeezing it."

Chloe was in so much pain that she couldn’t walk to the door and had to be taken inside in a wheelchair by her brother while Mrs Longster found a parking space.

In the paediatric A&E department Mrs Longster noticed how pale and clammy her daughter looked.

She was triaged and placed in a side room before being given oral Oramorph for her pain.

"She asked if she could be put to sleep because she was in so much pain,” said Mrs Longster

"She said to me ‘stop saying it’s going to be OK mum. It hurts.”

A cannula was inserted but it fell out while Chloe was still in A&E. The teen had her observations done and bloods and a chest x-ray were ordered by a doctor around 2.20pm. Mrs Longster and her son then had to take Chloe down to x-ray themselves.

Mrs Longster saw the x-ray and noticed what she thought was a mass at the bottom of Chloe’s lung.

When she returned to the A&E department she was told Chloe had a chest infection. A doctor prescribed antibiotics and she was given one dose before being admitted to the Skylark Ward.

Mrs Longster had to repeatedly ask doctors for more pain relief for her daughter.

"I remember making a comment that it feels like we are chasing her pain, not getting on top of it,” said Mrs Longster.

An on-call doctor then saw Chloe and told her mum she had pneumonia and would need to be admitted for intravenous antibiotics and fluids.

When they arrived on the Skylark Ward Mrs Longster went to the nurses’ station.

"I remember in A&E having to convince them she really wasn’t well,” she said.

"I was not a mum who’d been on google and she wasn’t a dramatic teenager.

"Somebody (on Skylark) asked ‘what’s your name’?

“I said I was Chloe Longster’s mum and they said ‘we know about her and we’ll be round’.

"I remember that sinking feeling because their interpretation of me had obviously transferred upstairs.

"I went back and messaged my husband and said I didn’t think they were taking it seriously. I was told by another mum that there was a poorly baby on the ward and, I get that, but my baby was poorly too.”

By 9pm Chloe had settled a little but was still wincing with the pain. No cannula had yet been fitted.

Mrs Longster was told that nurses couldn’t fit cannulas so a doctor came to insert one but was unsuccessful.

"A nurse kept coming in to do observations but nothing was happening,” she said.

"I asked what was going on and she said ‘she’s on red’. I thought to myself ‘don’t google it because I’ll panic’. But I shouldn’t have to google it.”

Mrs Longster had her head next to her daughter’s head on her pillow, with her feet on the pull-out parent bed.

"I told the nurse it felt really crackly,” she said.

The nurse did observations on Chloe and realised her oxygen had dropped.

"They initially thought the machine had broken,” said Mrs Longster.

Chloe was moved to a side room and Mrs Longster was told this was because she had tested positive for Influenza A. A consultant was called and more people began coming into Chloe’s room.

"I asked a nurse if she was going to be OK,” said Mrs Longster, “and the nurse said she didn’t know.”

"How I got out of the room I don’t know, but I just remember hitting the floor and being slumped there.

"It felt like Chloe hadn’t been taken seriously about how unwell she was until that point.

"She had asked me if she was going to die. I took that as her trying to articulate how poorly she felt. It’s haunting that the 13-year-old was the one who was right.

"During Chloe’s last 18 hours on this earth she was in pain and treated with contempt.”

Mrs Longster said that she got the impression nurses believed Chloe was being ‘dramatic’. She outlined an incident where a nurse abruptly told her that by breathing in the way she was, she was making her pain worse.

“I still think there were preconceived ideas,” said Mrs Longster.

"Chloe asked for her duvet to be brought in but I thought that was just going to exaggerate the diva teen thing.”

During her time on A&E, Chloe was seen by Dr Marwan Gamaleldin who was, at that time, a registrar.

He said a nurse had come to find him at about 2.20pm to ask him to see Chloe because she had started the sepsis screening tool but Chloe’s score had not been high enough to trigger further examination.

The court heard that during any admission at least one blood pressure should be recorded as part of observations to give doctors a baseline for each patient.

The doctor took her blood pressure on both arms during his own separate examination to see if there was a difference but he had no concerns.

Dr Gamaleldin did not record the blood pressure in his notes.

He was asked how many times he had seen Chloe in the two hours she was there. He said it was three or four and said that his notes were made retrospectively

"She didn’t come across as struggling to breathe,” he told the inquest.

“Breathing with pain is different to struggling to breathe.”

He said he began thinking about a ‘differential’ diagnosis than a bacterial infection because of her pain level and high heart rate.

"I saw a shadow on the left side of her lung in the x-ray,” he said.

"In that context, infection was likely.

"I remember saying that the pain wasn’t proportional to what we’d normally see in an infection.

"The absence of fever is a red flag. If there’s no fever and a high heart rate you start to think about something else.”

Later in the evening Chloe was intubated and taken to the intensive care unit.

The inquest, at The Guildhall in Northampton, continues until Friday.