Parents Liam and Lauren Marsh have waited years for an inquest into their daughter Bonnie’s death in December 2021.

They have remained adamant that more could have been done to save her by staff at the Norfolk and Norwich Hospital (N&N).

But an inquest into her death has ruled that this was not the case – however, they say they are not comforted by the findings.

Bonnie with her parents and brother (Image: Family)

The three-day hearing at Norfolk Coroner’s Court was told the little girl, who lived with her family on South Green in Dereham, had been taken to the N&N on two occasions in the days before her death.

Bonnie initially displayed cold-like symptoms, but her condition deteriorated and she began vomiting. At one stage she became unconscious, but still she was discharged both times.

She was assessed at the hospital on Thursday, December 16, and again on Friday, December 17, where staff determined she was well enough to return home after “showing no red flags”.

Norfolk and Norwich University Hospital (Image: Newsquest)

However, her condition worsened and she was taken back to the N&N on the morning of Saturday, December 18. A few hours later, she died after suffering a cardiac arrest.

Upon receiving the news of their daughter’s death, Ms Marsh said they were left “shaking and crying” and waited alone in a room with Bonnie for hours before being told what would happen next.

It has taken more than four years for an inquest into her death to be held, with her parents facing unexpected delays and long waits for evidence.

Bonnie Marsh died in December 2021 (Image: Family)

An interim death certificate recorded Bonnie’s cause of death as an “inborn error of metabolism” - a diagnosis which caused a lot of controversy during the inquest.

Johanna Thompson, area coroner for Norfolk, advised that her determination regarding the cause of death had to be “on the balance of probabilities”.

"In that regard I accept pathologist Dr Virginia Sams' revised opinion," she said.

“Dr Sams gave comprehensive evidence as to her findings at post mortem.

“She gave a reasoned opinion as to why she considered in the first instance that Bonnie died from an inborn error of metabolism.

“She gave evidence that...Bonnie’s heart was structurally normal.”

Johanna Thompson, area coroner for Norfolk. (Image: Norfolk Coroner's Court)

Ms Thompson recorded the medical cause of death as "coxsackie B virus type 2 infection and inborn errors of metabolism”.

The family had also been concerned that Bonnie was incorrectly discharged from the N&N.

On the second day of the inquest, evidence from Professor Mark Peters – who conducted a report into the death – said that the child may have been stabilised if she had been admitted “six to 10 hours earlier”.

Norfolk Coroner's Court in Norwich. (Image: Newsquest)

However, Ms Thompson said she found there were “no missed opportunities” by N&N staff.

“I have reviewed that it is not the case of a missed opportunity to provide necessary treatment,” she added.

“Rather Bonnie was provided with treatment for her presentation on each occasion based on her clinical presentation and judgement from staff."

The youngster’s parents were visibly upset at times throughout the inquest, with Ms Marsh leaving the room on one occasions in tears.

Ms Thompson recorded a conclusion of “natural causes”, offering her condolences.

Bonnie with her brother (Image: Family)

In a statement shared after the inquest, Mr Marsh, a transport manager, described being "deeply shocked” by the outcome.

He said: “I feel there was enough evidence provided over the prior days that could not prove Bonnie had the genetic disorder ‘inborn error of metabolism’. It is accepted that Bonnie had a viral infection ‘coxsackie B type 2’ and there were proven results of this.”

He also criticised N&N staff for not taking into consideration her raised heart rate and not taking blood pressure recordings on December 17, and questioned evidence from witnesses who said it was “difficult” to gain such results from stressed children.

"Bonnie lay between my legs on a hospital bed, lethargic and barely moving while being in hospital,” he said.

“This was also the case as they were able to carry out numerous blood gas tests, through obtaining blood via finger prick, without Bonnie even flinching.”

He added: “It was not until Bonnie’s passing when I requested her full medical records.

“Upon looking at the results, it was clear to see that there were numerous values on the results that were outside normal parameters.

“I am concerned that with so many values outside those parameters there was no intervention or acknowledgment from the medical team to bring these back into the acceptable parameters.

“All in all, Bonnie arriving back at the A&E department for a second time within 24 hours also being lethargic, vomiting and having a high heart rate – but being discharged hours later with no resolution apart from ‘suspected gastritis’ - does not sit well with my confidence as a parent regarding the level of care provided, although this has been deemed adequate.”

Bonnie Marsh died in December 2021 (Image: Family)

Also speaking after the inquest, Bonnie's mum - who asked for her statement to be attributed to her as Ms Zurawski after the couple's separation – said: “Myself and my family would like to thank everybody for their support over the last four years during this very challenging and often upsetting time.

“Your messages of love and support have really kept me going. I have met some amazing people through this process that are also grieving the loss of their child and wish them all my love as they carry their children’s memories into the future.”

‘A thorough internal investigation took place’

Following the conclusion of the inquest, the Norfolk and Norwich Hospital’s medical director Bernard Brett issued a statement.

Dr Brett said: “Our heartfelt condolences remain with Bonnie’s family and our thoughts are with them as they relive this very painful time in their lives. We hope the conclusion of a full inquest provides the opportunity for closure and we recognise how difficult it has been for the family waiting for answers.

"A thorough internal investigation took place following Bonnie’s death to examine the care she received and to identify any learning or actions to improve the overall care for future patients, which concluded in March 2022 and was shared with the family.

Dr Bernard Brett of the N&N (Image: Norfolk and Norwich Hospital)

"The decision not to admit Bonnie on December 16 or 17 has also been re-reviewed by a consultant in paediatric intensive care and a group of emergency medicine consultants.

"Clinical practices and processes have changed since this time including the roll out of Martha’s Rule, which gives families another route to seek an urgent review if their loved ones’ condition deteriorates.

"The NHS Paediatric Early Warning System (PEWS) was adopted at N&N in 2022, which is a national tool to identify, monitor, and respond to clinical deterioration in children and young people. Advice leaflets have also been produced for when an unwell child is discharged from the children’s emergency department.”

What is Martha’s Rule?

Martha’s Rule is a new NHS patient safety measure that gives patients and their families a formal way to ask for an urgent second opinion if they are worried someone is getting worse in hospital and feel their concerns are not being heard.

It was introduced after the death of 13‑year‑old Martha Mills, whose parents’ fears about her deterioration were not acted on. Under Martha’s Rule, hospitals must clearly advertise a dedicated phone number or contact route that allows patients, relatives or carers to trigger a rapid review by a senior team member not already involved in the person’s care.

Staff can also use the system if they feel worries about a patient are being overlooked. The aim is to spot deterioration earlier, flatten medical hierarchies and ensure that when families say “something isn’t right”, the system is obliged to take that seriously.

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