A six-year-old Doncaster boy’s life could have been saved if he had been given antibiotics on the evening he was admitted to hospital.
Coppice Special School pupil Marc Poole, known as MJ, was taken to Doncaster Royal Infirmary after suddenly falling ill, an inquest heard. Doctors suspected he was suffering from meninigitis and he died two days later.
But the little Mexborough lad would have survived if doctors had not delayed in giving him lifesaving medication, Doncaster Coroner’s Court heard.
His family said in a statement: “We are hopeful that all those involved in MJ’s treatment are able to reflect upon their involvement to ensure that another little child like MJ is not treated in the same way, and that no other family has to go through the pain that we have experienced in these circumstances.”
Recording a narrative verdict, Nicola Mundy, senior Coroner for South Yorkshire East, said MJ died from an infection which led to septic shock, causing his organs to fail.
She said doctors, who had decided to wait for test results before giving MJ the drugs he needed, had put ‘too much reliance on observations and too little on the bigger picture’ .
MJ’s mother, Sharon Carver, had previously told the inquest he had seemed ‘his normal self’ on Saturday, May 16 last year – two days before his death – but he had said his head hurt so she gave him some Calpol.
Later in the day, MJ had become lethargic and after calling the out-of-hours doctor, Miss Carver took him to Doncaster Royal Infirmary.
His symptoms included vomiting, a rash, lethargy and a high temperature.
MJ’s condition worsened and he was transferred to Sheffield Children’s Hospital – but doctors were unable to save him and he died in the early hours of May 18.
Ms Mundy said: “MJ was admitted to hospital with a suspicion of infection with no focus.
“Prolonged assessment and investigation delayed provision of antibiotic therapy. Had this commenced on May 16, it is likely MJ would have survived from the effects of pneumococcal septicaemia.”
Pneumococcal septicaemia is an infection which can result in pneumonia, infection of the blood, a middle-ear infection or bacterial meningitis.
The Coroner said she will issue a Regulation 28 report – which highlights concerns to prevent future deaths – to Doncaster and Bassetlaw Hospitals NHS Trust, NHS England and the Chief Coroner.
She said she would recommend that symptoms of paediatric sepsis are made clear to staff.
A worried Miss Carver had shown doctors and nurses in DRI photographs of a rash on MJ’s skin, which would appear and then fade away again, but was told it was nothing to be concerned about.
Ms Mundy said she had concerns about ‘poor communication’ between staff and added: “I did not feel enough weight was given to the parent’s input and history.”
The inquest heard observation charts were poorly completed and a doctor was not told the results of a blood test which checked for infection.
Mr Sewa Singh, medical director at Doncaster and Bassetlaw Hospitals, said: “We would like to extend our sincerest apologies to the Poole family for the failings in the standard of care that HM Coroner found had contributed to the tragic loss of their son Marc.
“As a result of the concerns raised by HM Coroner we will undertake a further review of the systems and processes in place to ensure that we are taking all of the measures we can take to reduce the risks of a delayed diagnosis of sepsis in children.”
MJ’s family are now raising money for Meningitis Research Foundation and have set up an online fundraising page in his memory.