“Serious failings” at Colchester Hospital led to the death of a 14-year-old girl from pneumonia, an inquest has ruled.

Josie Cotier passed away at her home in Clacton on October 22 last year, two days after visiting Colchester Hospital’s children’s assessment unit.

At Chelmsford Coroner’s Court on Friday, Area Coroner Caroline Beasley-Murray drew a narrative conclusion, saying Josie had died because of the standard of care at the hospital.

She said: “A specialist paediatric postmortem examination was carried out by a pathologist.

“He has given her cause of death as bronchopneumonia as well as recording myopathy and learning difficulties, conditions which were present but not the main cause of death.”

She added: “There were serious failings in the care provided by Colchester Hospital and if appropriate care and treatment had been provided she might have survived. The root cause analysis investigation has created an action plan and the court pleads with the hospital to make sure it is fully implemented.”

Coroner’s officer Alan Clements told the court Josie’s parents initially took her to Colchester Hospital on October 20, 2017, because she was suffering from a possible chest infection and diarrhoea.

However she was send home the same day, despite there being warning signs she was suffering from sepsis.

He added: “At home on October 22, 2017, she was found unresponsive in bed.

“CPR was started by her parents until the paramedics arrived and declared her deceased.”

Dr Andrea Turner, clinical director at Colchester and Ipswich Hospitals, prepared a root cause analysis report after the teenager’s death.

She said there had been a failure to follow the paediatric warning rules for sepsis.

“The patient had some signs at the time, she had a rapid heartrate and rapid breathing rate,” she said.

“With the sepsis warning system there would be a red and two amber flags. It was the finding of the investigation this was not taken into account and her examination was not significant.”

There had also been a failure to act on Josie’s blood results, which had shown warning signs of infection. If the infection had been caught and treated, Dr Turner said Josie could have survived.

Dr Turner apologised to the family and said the tragedy had led to an overhaul in children’s assessment unit’s management of sepsis and an action plan of changes had come from the production of the report.

She added: “It is work in progress and I believe we have made a lot of changes but there is always room for improvement and we are striving to make sure we keep improving.”

Mrs Beasley-Murray expressed her sympathy to the Josie’s family, who were present at the hearing.