A delay in administering antibiotics to a three-month-old boy with sepsis amounted to a “gross failure” by medical staff, an inquest has concluded.
Lewys Crawford, from Cardiff, died the day after being admitted to A&E at the University Hospital of Wales with a high temperature in March last year.
The three-month-old was first seen at about 8.30pm on March 21 but he was not given broad spectrum antibiotics until about 3am the following day, an inquest held at Pontypridd Coroner’s Court heard.
A jury concluded a failure to treat Lewys with antibiotics before 11.30pm “significantly contributed” to his death.
Senior coroner Graeme Hughes summed up the evidence heard over the course of the five-day inquest on Friday.
Mr Hughes said Lewys’ mother, Kirsty Link, said her son had been his “normal self” until about 4pm on March 21 when she discovered he had a temperature.
She gave him some Calpol but took him to A&E in Cardiff at about 8.15pm when his condition did not improve.
Mr Hughes said nurses observed he had a fast respiratory rate, heart rate and a high temperature.
Dr Jo Mower told the court she examined Lewys at about 9.15pm.
Mr Hughes said Dr Mower said she had assessed Lewys as a “hot child rather than a septic child” but accepted this was the wrong diagnosis.
Mr Hughes said Dr Mower accepted that if she had followed guidelines related to septic risk she “would have come to a different conclusion”.
In her evidence, Dr Ifeoma Ujomu said she examined Lewys at 10.30pm and suspected a bacterial infection but “didn’t suspect he had sepsis”. She accepted this was an “error of judgement” on her part.
She accepted she was familiar with the NICE guidelines. She admitted she should have given antibiotics at the earliest opportunity by any possible means.
Dr Ujomu told the jury she saw Lewys again at about 12.30am the following day by which point he had been cannulated and fluids given.
The jury heard Lewys was not given broad spectrum antibiotics until about 3am on March 22.
He died at 11.10pm the same day.
Lewys’ cause of death was recorded as meningococcal septicaemia (Group B).
What is an inquest:
Mr Hughes said expert witness Professor Parviz Habibi told the jury if antibiotics had been administered at any time up to 11.30pm on a balance of probabilities Lewys would have survived.
He added that it was only “possible” that Lewys would have survived if antibiotics were administered after 12.30am.
After retiring to consider on Friday afternoon, the jury returned their conclusion.
The jury foreperson said: “It is likely Lewys was in the early stages of meningococcal disease when he was admitted to accident and emergency at the University Hospital of Wales on 21 March at 8.15pm.”
The jury said there were “multiple opportunities missed” to identify Lewys as high risk of sepsis and a “failure to treat Lewys with antibiotics before 11.30pm”.
The jury found this “significantly contributed” to his death.
The jury recorded a conclusion of death by natural causes contributed to by neglect.
The foreperson said there was a “gross failure up to and including 11.30pm on March 21, 2019”.
Coroner Graeme Hughes said he would consider whether a report into the prevention of future deaths was appropriate in this case.