Medical neglect contributed to boy's sepsis death
Medical neglect contributed to the death of a three-year-old boy who developed a strep A infection and later died of sepsis in hospital, an inquest jury has found.Oscar Neillings had been unwell days before he was rushed to the Chesterfield Royal Hospital in Derbyshire in November 2023 but he was not given antibiotics he needed until more than two hours after being admitted.The inquest heard his care at the hospital was "fragmented" with his sepsis missed and his parents saying they were not told how ill their son was.Hospital bosses said they accepted the findings of the inquest.
Speaking after the verdict, Oscar's mother Stephanie Neillings said: "I am so grateful that the jury were able to see clearly what happened... the hospital left Oscar to die."
The jury reached a narrative conclusion and said Oscar died from natural causes contributed to by neglect.Jurors were instructed to record Oscar died from sepsis following bronchopneumonia and invasive strep A infection.Assistant coroner for Derby and Derbyshire Julie Mitchell said she would not be issuing a Prevention of Future Deaths report as she was "satisfied changes have been implemented to improve patient safety" at the hospital.The inquest previously heard from Oscar's mother who criticised medics who treated her son in hospital and "thought she was being crazy" when she suggested he had sepsis.Jurors heard strep A infection was not considered when Oscar attended two out-of-hours GPs appointments on 5 and 7 November.Instead his parents were told he had a "viral upper respiratory infection" and "did not consider he would deteriorate", the coroner said.
After his condition worsened he was seen again at his family GP surgery the next morning where he had a nebuliser put on him and was taken to hospital under blue lights.Oscar was seen by clinicians who found he had low oxygen levels and a poor respiratory rate.He had a chest X-ray, which showed "significant right-sided consolidation" and was given intravenous fluid and steroids.
Mrs Neillings told the court doctors spoke about a chest infection and they were going to administer antibiotics but said care was "unorganised"."I had absolutely no idea how poorly he was until right at the end," she said.Oscar arrived at the hospital at 10:30 GMT but was not given antibiotics until 12:54 due to "delays" from a "prescribing error", the inquest heard.Mrs Neillings said a matron came to check on Oscar later in the day and said he had deteriorated and paged for a doctor just before 15:00 and he was taken into intensive care.Oscar went into cardiac arrest three times and died just before 17:30.
The Derbyshire Times reported consultant paediatrician Dr Nelly Ninis of London's St Mary's Hospital told the jury sepsis was "not recognised" in Oscar by staff at Chesterfield Royal Hospital, adding no-one really "owned" Oscar's care – which she described as "fragmented".The court was told how there was evidence Oscar was in septic shock the morning of his transfer to hospital, the newspaper said.Dr Ninis said under National Institute for Clinical Excellence sepsis protocols, a high dose of antibiotics and "rapid infusions of fluid" were needed within the first hour to reverse septic shock, it added.The jury heard Oscar did not receive antibiotics after nearly two and a half hours in hospital and only 10ml of fluid – when he required at least 60ml, the Derbyshire Times said.
Speaking to the media on the steps of Chesterfield Coroner's Court following the verdict, Mrs Neillings said: "Our darling little boy was taken away from us and he can't come back."We long for our life to be how it was but have to adapt to this new normal, carry on and carry Oscar with us."I don't want him to be known for how he died, I want Oscar to be known for how he lived, his short life was so full of energy, happiness and love and we will be forever grateful for Oscar."
Helen Reynolds, medical negligence lawyer at Fletchers Solicitors who represented the family during the inquest, said they were now pursuing a civil claim against Chesterfield Royal Hospital NHS Foundation Trust.She added the trust said it had produced an action plan but had not made it public."This inquest has brought painful clarity to what went so tragically wrong in Oscar's case," she said."The failings in his care are deeply distressing but the family's courage in sharing their story must lead to action."Any changes must be accompanied by clear deadlines, measurable outcomes, and complete transparency. "Families deserve assurance that these commitments are being honoured and no other child will be failed in the same way."
Krishna Kallianpur, executive chief nurse at the trust, said: "At the heart of this is a family who have lost their three-year-old son and for that we offer our sincere condolences."We have submitted a full learning review and acknowledge the findings of HM The Coroner with the conclusion of natural causes contributed to by neglect. "We will continue to embed the actions taken to date to ensure that we continue to learn and improve."
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