Boy who died from sepsis ‘may have lived’ if hospital had family’s phone number
A young boy who died from sepsis after being discharged from hospital could have survived if staff had managed to contact his family with his test results, an inquest heard.
Four-year-old Sheldon Farnell died the day after he left Sunderland Royal Hospital, and almost three days after his mum first took him to the A&E unit after he showed symptoms that could have been warning signs of sepsis.
Coroner Derek Winter heard on Monday how Sheldon’s condition had improved so much that medics sent him home despite the fact that the definitive blood culture test results had not yet come back.
Experienced paediatrician Dr Geoffrey Lawson described his decision to discharge Sheldon from hospital the day before his death as his “lifelong regret”, Chronicle Live reports.
Minutes after Sheldon’s family left the hospital, Dr Niresha Sirinanda, a senior paediatric trainee at the time, was told the boy’s final blood culture tests returned a ‘gram positive’ result for Group A streptococcus – a bacteria that can cause sepsis.
Despite numerous attempts to contact the family, they were unsuccessful in getting through, with a statement from Sheldon’s mum confirming all three numbers on record were not in use.
Sheldon died on the morning of November 26, 2018.
During the third day of the week-long inquest, Dr Mark Anderson, who is a consultant with years of experience in paediatrics, told Coroner Derek Winter: “If they had been able to contact Sheldon’s family at that time I doubt we would be sitting having this conversation.
“Opportunities to start antibiotics are kind of insignificant because this would be the time when antibiotics could be started and would have made a difference and that’s the real tragedy here.”
He added: “If Sheldon has deteriorated following his initial admission then he would have received antibiotics.”
Dr Anderson said despite tests showing Sheldon’s CRP was raised that it was “reasonable” that antibiotics were not given on admission.
The doctor said: “The only real thing that leans towards a serious bacterial infection is the raised CRP at this stage. It would be a reasonable course of action not to start antibiotics at this stage.”
Dr Anderson however said he was “surprised” antibiotics weren’t started following the lumbar puncture.
He said: “There was something unusual that was happening here, something that we are not aware of as it’s not been documented in the medical notes.
“Why would one perform a lumbar puncture on a well-looking child?”
The doctor also said medical staff “rely” on contact details of patients being checked during check-in.
The inquest then heard the events leading up to Sheldon’s death from Holly Rebecca Keegan, the partner of Sheldon’s mum Katrina.
Sheldon, from Houghton-le-Spring in Tyne and Wear, was being looked after by a family member overnight on November 21 when they explained how he had been “screaming in pain” because of pain in one of his ears.
The following day, he was out with his grandparents and had a hat covering his ears which he “would not take it off”.
Holly explained: “He was asleep on the sofa. His face was luminous red, his cheeks were glowing, other than that he was pale and was just asleep the whole time.”
After taking him into Sunderland Royal Hospital, Sheldon was checked over by a nurse who Holly said was “quite concerned” about him.
She said: “He was asleep on the bed and he started making jerking movements with his hand putting them outwards. He was also talking jibberish and was making comments that didn’t make any sense.”
A blood test revealed that Sheldon had an infection but at that time they “didn’t know what it was” and due to concerns that Sheldon may have meningitis, a lumbar puncture was performed.
Holly said: “He was very restless. He didn’t want to be out of bed, he just wanted to sleep.”
She said Sheldon “looked a lot worse” when she visited him on Saturday.
Sheldon was discharged from the hospital on the Sunday, the day before his death, but Holly explained how there were still concerns over his condition from loved ones.
She told the inquest: “My dad was walking past and had seen Katrina carrying Sheldon into the house and he said: ‘What the hell is that bairn doing home, have you seen the state of him?’
“He works in a hospital so knows what ill patients look like.”
On Sunday, Sheldon was with his grandmother so that Katrina could get some sleep but after suffering vomiting, diarrhoea and swelling to his face and arm, he was rushed back into hospital in the early hours..”
At hospital, Katrina told Holly over the phone that Sheldon had blood poisoning and that the next 12 hours were “critical” but he died on the Monday.
Holly told the inquest: “They never informed us about anything. We asked about the blood result but they never informed us that there were any problems at all. They just said ‘we think the test results are okay.’
“They never mentioned CRP, they never mentioned streptococcus, nothing like that.”
The coroner then asked the witness what was asked about contact details at the hospital.
Holly said: “They just said ‘is the information up to date’ and I said ‘I’m not sure.’
“I asked Katrina and she said her mum will have updated when he had an appointment last month.”
Dr Joshua Bennett said in a statement that Sheldon was brought to the hospital shortly after 10pm after vomiting, feeling sleepy and suffering from headaches.
He also explained how Sheldon’s mother became concerned after he became confused, saying to her: “I’m going to go away in a police van.”
The doctor explained how he decided to carry out a lumbar puncture because, although he “didn’t strongly suspect” he had meningitis, he said the only way to find out was to perform a lumbar puncture.
He said he did not administer antibiotics to Sheldon as he “couldn’t see any clinical sign of serious bacterial illness or sepsis”.
Dr Paul McAndrew, Deputy Medical Director at South Tyneside and Sunderland NHS Foundation Trust said that following Sheldon’s death a number of changes have been implemented.
Five recommendations were made including how contact details were recorded.
The inquest continues.