Viviana-Ray Butnaru died on October 25, 2024, from myocarditis caused by Parvovirus, with bronchiolitis and bronchopneumonia as contributing factors.
In a newly published prevention of future deaths report, Assistant Coroner for Essex Jyoti Gill, identified critical failings at Basildon Hospital.
This included missed warning signs, poor monitoring, and inadequate escalation of care.
Trust bosses have apologised to the family for missed opportunities and said “learning” from the death has been shared to raise awareness in clinical teams.
Viviana-Ray was admitted to the Children’s Emergency Department just before midnight on October 24, 2024.
Chest X-rays taken that night showed signs of cardiomegaly, but the findings were not formally reported by radiologists until five days later, after her death.
Although an emergency doctor suspected the abnormality, this concern was passed on verbally and not documented.
The paediatric registrar later stated she had no recollection of receiving this information.
The coroner said the registrar failed to identify the enlarged heart on review and did not check blood gas results that showed metabolic acidosis.
Nursing and monitoring shortfalls were also documented, including a failure to follow the Children’s Early Warning Tool, not recording blood pressure readings, and neglecting a required sepsis assessment during triage.
Following an initial consultant review at 10.15am, Viviana-Ray was not reassessed until 4pm, despite ongoing clinical concerns.
By 9pm, she was in suspected heart failure and suffered a cardiac arrest soon after, passing away at 10.37pm despite 51 minutes of CPR.
Expert evidence indicated that while Parvovirus-related myocarditis progresses rapidly and can be fatal once heart failure begins, earlier recognition might have allowed for specialist input or additional investigations.
The coroner has now issued a formal warning to The Mid and South Essex NHS Trust
The trust is required to respond by April 29, 2026, detailing how they plan to address the identified failings and prevent future deaths.
Christine Blanshard, chief medical officer for Mid and South Essex NHS Trust, said:“Our thoughts and condolences are with Viviana-Ray’s family and we are sorry there were missed opportunities in her care.
“Myocarditis as a result of parvovirus is an uncommon cause of illness in children, so we have shared the learning from Viviana’s sad death to raise awareness in our clinical teams of the signs to look for and improved clinical observations.”