See the response from the NHS Executive Medical Director, Mark Pugh. This in from Caitlin Thomson-Harris from Novum Law on behalf of Leon Hamman’s family. Ed
On Tuesday 22nd April 2014, Mr Keith Wiseman HM Coroner for Southampton and New Forest recorded a verdict of “Death by Natural Causes” following an Inquest into the death of Leon Hamman, aged 5, from East Cowes on the Isle of Wight.
Leon’s family instructed Darren O’Sullivan and James Edmondson at Specialist Solicitors, Novum Law, on the Isle of Wight and Camilla Church, Barrister at 39 Essex Street, London, to represent the interests of Leon’s family at the Inquest.
Succumbed to severe sepsis
Leon tragically died on 19th December 2013 at Southampton General Hospital after succumbing to severe sepsis. Leon’s family were advised by doctors at Southampton to withdraw his life support when it was revealed that he had developed septic shock which was untreatable.
Leon, who had Chronic Granulomatous Disease, an underlying disorder which weakens the immune system and making sufferers more susceptible to infection, was admitted to St Mary’s Hospital on the Isle of Wight on the morning of 17th December 2013 with a rash, fever and vomiting, amongst other symptoms.
Failure of IW NHS staff
Mr Wiseman’s Verdict confirmed that at 11am Leon suffered from severe sepsis and that this was a failure on behalf of the staff at St Mary’s “to recognise this and treat accordingly”.
Between 11am and 11pm on 17th December 2013, staff at St Mary’s Hospital failed to check Leon’s blood pressure. Leon was not provided with intravenous fluids nor were his blood gas levels checked.
At the Inquest, Mr Wiseman was informed by an Expert in Paediatric Intensive Care that blood gas analysis should have been a “fundamental part” of Leon’s assessment during that time. Mr Wiseman reached the decision that the hospital’s failure to fulfil this basic requirement was due to a “slightly curious willingness to consider that Leon had a relatively minor problem”.
Coroner: “Single biggest contributory factor”
Mr Wiseman also accepted the findings of St Mary’s Hospital’s own investigations into Leon’s death that the hospital’s Paediatric Early Warning System (PEWS), a ‘score-card’ designed to alert staff to a dramatic change in a patient’s condition had failed, meaning that Leon’s condition was thought to be less critical than it actually was.
Mr Wiseman said,
“This was, I believe, the single biggest contributory factor in failing to recognise the severity of the condition at the earliest opportunity”.
New systems being implemented
St Mary’s Hospital informed the Coroner that they are now in the process of implementing a new PEWS Chart as a result of Leon’s death, along with eight other recommendations for improvements at the hospital.
Mr Wiseman said that the implementation of these recommendations “is crucial to ensure that St Mary’s is able to deal appropriately with similar issues”.
Coroner: “St Mary’s struggling to get their act together”
By 11pm on 17th December 2013, Leon had gone into septic shock. Unfortunately, Mr Wiseman said that “St Mary’s seem to have been struggling for some time to get their act together” and that they had deprived Leon of “the best possible opportunity [of] successfully overcoming [the] crisis”.
Leon sadly passed away in the morning of 19th December 2013 at Southampton General Hospital when he succumbed to septic shock and his parents were advised by the treating doctors to withdraw life support.
Parents’ disgust st hospital
Leon’s parents, Michael and Tasha, said
“We are disgusted that a hospital can fail to recognise and treat such a serious condition as that which killed our little boy.
“We can only hope that St Mary’s will learn from the errors highlighted by the Coroner and that no parent will ever have to say goodbye to their child in this way again.”
Love u Thousands charity
Leon’s family have recently set up a charity, ‘Love u Thousands’, in memory of Leon. The charity raises money in order to fund travel and accommodation expenses for family members of seriously ill children to visit them when they are being treated on the mainland, see www.loveuthousands.co.uk for details.
Leon’s mother said,
“This is a way to keep Leon’s spirit alive. Love u Thousands will not bring him back, but if some good can come out of this tragedy then at least that counts for something.
“We know all too well how difficult it can be to have a child away from home. Leon was constantly in and out of hospital at Great Ormond Street and it became difficult at times to be able to afford for people to come and visit him.”
Following the Inquest, Darren O’Sullivan a Solicitor at Specialist Medical Negligence Solicitors, Novum Law, commented:
“Today was the first step in helping Leon’s parents to understand why their son passed away from what could have been a treatable infection. As the Coroner said himself, sadly Leon was not given the best possible chance to overcome the sepsis as a result of the hospital’s failure to recognise and treat him appropriately.
“Leon’s family must now try to come to terms with the fact that, had Leon been treated appropriately, there is a chance that he would still be with us today. They can now only hope that the hospital act upon the Coroner’s recommendations for improvement and that the significant failings which he identified will be rectified”.
Following the Inquest, Leon’s parents are seeking further legal advice from Specialist Solicitors at Novum Law in respect of a claim for Medical Negligence against the Isle of Wight NHS Trust on behalf of Leon.
