A poorly toddler who died after being discharged from hospital despite a severe infection is ‘highly likely’ to have survived had doctors followed proper procedures and prescribed antibiotics, an inquest found today.
The damning conclusions after a three-day hearing into the death of Olly Stopforth, aged 15 months, were described as ‘incredibly painful and difficult’ for his parents Laura and Karl Stopforth.
Olly died a little under 48 hours after being discharged from the Countess of Chester Hospital at 3am on March 21, 2020.
The inquest, in Warrington, Cheshire, heard he was sent home with advice for his parents to give him Calpol and ibuprofen – despite showing signs of scarlet fever. A post-mortem examination found he died of Strep A infection, which can lead to sepsis.
Doctors said they were under pressure while dealing with two other seriously-ill children and because it was the beginning of the Covid pandemic.
Olly died a little under 48 hours after being discharged from the Countess of Chester Hospital
The damning conclusions after a three-day hearing into the death of Olly Stopforth, aged 15 months, were described as ‘incredibly painful and difficult’ for his parents Laura and Karl Stopforth (pictured above with their solicitor Diane Roystron, centre)
In a narrative conclusion, the jury said there were ‘a number of missed opportunities in Olly’s care’ – including no tests for viral infection, a lack of communication between medical staff and a failure to build up a ‘complete picture’ of his condition.
Jurors said: ‘Nothing was specifically done to rule out a bacterial infection, nor was a comprehensive plan put in place for reassessment.
‘The Countess did not follow (the) NHS UK sepsis tool or NICE (National Institute for Healthcare and Clinical Excellence) guidance which, if used, would have indicated the need for blood tests and/or antibiotics.
‘The adequacy and thoroughness of assessment was not sufficient. Had this been sufficient, Olly’s chance of survival would have been highly likely.’
The jury described how fears of sepsis were passed on by the paramedic when Olly arrived at A&E – and that his observations were ‘grossly abnormal and (those) of a very sick child.’
Mr and Mrs Stopforth’s solicitor Diane Rostron said outside court: ‘Hearing from the professionals involved in Olly’s care that more should have been done to properly diagnose what was causing his illness, and that providing antibiotics would have resulted in a full recovery, has been incredibly painful and difficult for Laura and Karl.
‘Laura and Karl felt Olly was not considered as a priority when he was in hospital.
‘The seriousness of Olly’s condition was recognised by the paramedic who properly alerted her colleagues in advance. Tragically, the care provided to him when he got to the hospital fell well below acceptable standards and they failed to provide the care Olly so badly needed.
Doctors said they were under pressure while dealing with two other seriously-ill children and because it was the beginning of the Covid pandemic
Parents Laura and Karl Stopforth arrive at the inquest at Warrington Coroners Court, Cheshire
‘No parent should lose their young child as they have, it is especially painful because they lost their beautiful boy in preventable circumstances.’
Ms Rostron added that Olly leaves behind an older brother Finlay, 8, ‘who still misses him desperately’.
She added that doctors who saw Olly ‘could not see what was staring them in the face – Scarlet fever’.
Scarlet fever and Strep A are caused by the same type of bacteria – and both can lead to sepsis.
The trust has admitted liability for Olly’s death, the inquest heard.
His family are now pursuing a medical negligence claim against the trust.
A pathologist found Olly died from Strep A, a bacterial infection which can cause sepsis, but which could have been treated with antibiotics.
Mrs Stopforth, 40, broke down as she told the inquest how she found her baby son dead in bed minutes after Mother’s Day had ended.
Olly had been discharged at 3am two days earlier despite a high temperature of 40.7C, an extreme heart rate of 202 and a respiratory rate of 60, and a rash that a nurse feared was Scarlet Fever – another bacterial infection which can lead to sepsis – because it had the texture of sandpaper.
He was taken by ambulance to the Countess on the evening of Friday March 20, 2020 but his father Karl Stopforth claims doctors then failed to carry out a ‘hands on’ check on Olly.
He was found dead after Mr Stopforth, a baker, set his alarm for 12.15am on Monday March 23 because he was on an early shift and his wife got up with him to check on her baby son.
Sobbing, Mrs Stopforth recalled: ‘I went into Olly’s room and I just knew …. that he had passed away.
‘I picked him up and ran to the top of the stairs and shouted at Karl to ring an ambulance.’
Mr Stopforth, 39, recalled how on their earlier arrival at hospital Olly had to wait almost six hours in accident and emergency before he was allocated to a ward.
He told how an ambulancewoman Lynsey Field had radioed ahead with a red alert because of Olly’s abnormally high readings for heart rate, breathing and temperature and specifically warned doctors he might have sepsis.
But, he claims, doctors failed to carry out a proper examination of his son and instead relied on ‘observing’ him from the end of the bed.
Dr Kieran McCarthy, who discharged Olly despite his symptoms of scarlet fever and sepsis
Asked by senior coroner Jacqueline Devonish if he believed his son had been properly examined, Mr Stopforth said: ‘No, not at all. The doctors did not really talk to me. No-one, doctors or nurses spoke to me about the rash either.
Paramedic Ms Field, who believed he might have sepsis, told the inquest she had warned medical staff on arrival at the hospital of Olly’s seriously abnormal readings for temperature, breathing and heart rate.
Accident and emergency nurse Laura Stanton said she believed he might have Scarlet Fever but described how difficult it was for her to advise tests when she was in the presence of a consultant and a doctor.
Consultant paediatrician Alison Timmis, who was on duty the night he was admitted, admitted his condition should have been monitored more thoroughly.
She also accepted it was a mistake to send him home after one set of observations should his temperature, heart rate and breathing had fallen despite the previous six observations showing really high abnormal readings.
She apologised directly to Olly’s family, telling them: ‘His death has profoundly affected everyone involved.’
Dr Kieran McCarthy, who was responsible for discharging Olly back to the family home in Frodsham, Cheshire, said: ‘At the time the fear was that keeping people in hospital potentially longer than they needed to be was putting them at risk.’
But he added: ‘On reflection, I should have done a more thorough assessment and I should have examined him.’
Dr Nigel Scawn, Medical Director at the Countess of Chester Hospital NHS Foundation Trust, said: ‘On behalf of the Trust I would like to extend my sincere condolences to Olly’s family.’
‘More investigations should have been done while Olly was in our care to fully diagnose and treat the underlying cause of his illness.
‘The Trust has considered this in detail, and lessons have already been learned as a result.
‘We have further embedded Local and National Guidelines in our work to help staff better identify and treat sepsis, including how to recognise when to administer antibiotics if sepsis is suspected.’