Senior coroner for West London to hold inquest into the death of five year old boy from bacterial pneumonia with sepsis following treatment at Hillingdon Hospital

Posted: 21/03/2017

An inquest in relation to the tragic death of a five year old boy, known as A J, who died following treatment at Hillingdon Hospital on 22 December 2015 will commence today.

Background

On 21 December 2015, A J’s mother took him to see his GP with a temperature, a cough, and a rash over his body. His chest seemed clear on examination, and his mother was told to ensure that her son rested and drank plenty of fluids. A J was prescribed cough syrup, Cetirizine for his rash, and Dioralyte to rehydrate him.

During the night, A J began to suffer from diarrhoea. His cough became wheezy, and he continued to have a high temperature. By the early hours of the morning, his parents decided to take him to the accident and emergency department of Hillingdon Hospital, and they arrived just before 4am. He was admitted to the paediatrics ward and a medical history was taken. A J was initially treated for croup (a viral respiratory infection) and was given oral steroids and provided with an oxygen mask. When his cough did not improve, he was transferred to the resuscitation area of the accident and emergency department at 4.15am.

A J became agitated. His heart rate and breathing rate were abnormally high, and his oxygen saturation levels were low. Despite his deteriorating condition, which was not improving with treatments for croup, alternative diagnoses were not considered by Hillingdon Hospital doctors.

At approximately 12.15pm, doctors tried to cannulate to take bloods and administer IV antibiotics. Their attempts were unsuccessful and A J was getting increasingly agitated so it was decided to try again later. A further attempt to cannulate was made at 2.30pm, and doctors noticed a non-blanching rash under A J’s armpits. At this point, sepsis was suspected, and blood tests and a chest X-ray were ordered. The X-ray showed right lower lobe consolidation, and blood results demonstrated metabolic acidosis and a high lactate level, indicative of sepsis. IV antibiotics were administered and an assessment of toxic shock syndrome was made after almost 12 hours in A&E.
 
The hospital anaesthetics team was called, and the Children’s Acute Transport Service (CATS) from Great Ormond Street Hospital was contacted at 4pm. On arrival at 6pm, they tried to stabilise A J, and a decision was made to transport him to Great Ormond Street Hospital to use extracorporeal membrane oxygenation (ECMO) equipment which was felt to be his best chance of survival.

At 8pm, A J was transferred by ambulance to Great Ormond Street Hospital. He suffered cardiac arrest during transfer, and CPR was commenced. Attempts to resuscitate continued on arrival at the hospital, but A J very sadly passed away soon after 9pm. A post-mortem carried out showed the cause of death to be bacterial pneumonia with sepsis.

Admissions made by the trust

Prior to the inquest the trust has admitted that on 22 December 2015:

• A consultant paediatrician should have been asked to review A J at 7.30am;
• At or around the same time, there should have been urgent baseline blood tests, blood gas analysis and a chest x-ray; and
• Intravenous antibiotic treatment should have commenced by 8am

Further, the trust has admitted that had the above steps been taken it is more likely than not that A J’s death would have been prevented.

The inquest will take place before HM Assistant Coroner for West London, Dr Sean Cummings, at the West London Coroner’s Court.

Rosie Nelson, an associate in the clinical negligence team at law firm Penningtons Manches, is instructed by the deceased’s family to represent them at the inquest. She said: “This is a tragic event involving the avoidable death of such a young boy, and raises serious questions and concerns surrounding the treatment he received in hospital. It is hoped that the inquest will help to provide the family with some solace in answering some of the questions arising from his death. We are extremely pleased that the trust has admitted the failures regarding the care that AJ received. It is hoped that lessons are learned and that A J’s sad death will help prevent further unnecessary deaths.”

The family has said: “We would like to thank our family members, friends, A J’s school and Jesus House, London, for all their support, prayers and encouragement at our time of bereavement. We pray no other family has to go through this tragic and sorrowful episode of losing their child unnecessarily.”

An article on this case appeared in The Sunday Times on 2 April 2017. Please click here to view the full report.

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