‘On the balance of probabilities, had there been earlier intervention, he would have survived’
Tameside hospital (stock image)(Image: M.E.N.)
The death of a five-year-old boy with sepsis was ‘contributed to by neglect’ amid ‘gross failings’ in his care at a Greater Manchester hospital, a coroner has concluded.
Pak Lam Law was transferred to Tameside Hospital from Salford Royal on December 4, 2023 following a pneumonia diagnosis. He died the next day, an inquest into his death at Stockport Coroners’ Court heard.
Coroner Alison Mutch was told he went into cardiac arrest just before 9.30am. On Friday (June 20), she concluded Pak died from natural causes – multi-organ dysfunction due to septic shock – ‘contributed to by neglect’.
Ms Mutch identified ‘gross failings’ in his care. “On the balance of probabilities, Pak would have survived, had there been earlier recognition of his deteriorating condition, and earlier intervention and escalation,” she said.
The coroner earlier said Pak was transferred to Tameside as there were no available paediatric beds in Salford. He had a chest X-ray prior to the transfer, which revealed a build-up of fluid in his right lung.
Pak was diagnosed with pneumonia and put on antibiotics. “There appears to have been a doctor-to-doctor conversation upon his transfer to Tameside, but that was not recorded,” Ms Mutch said.
“It is unclear if the fact of the fluid in his lung was adequately conveyed. It is not possible to say where this communication breakdown occurred.”
The court was told Pak was deemed to stable at Tameside Hospital, but that it was ‘too late’ in the day to perform an ultrasound scan which may have ‘provided clarity’ on his condition.
By 12.30am December 5, he began showing ‘signs of deterioration’. “This was not escalated by nursing staff to the clinical team,” Ms Mutch said. “It should have been,” she added.
“The opportunity for a clinical review at this point – to recognise that Pak was deteriorating and consider escalation – was lost.”
By 1am observations, noting various markers like heart rate and blood pressure, indicated Pak was deteriorating further. “This was not escalated to the doctor,” Ms Mutch said. “It should have been.”
At 2.30am Pak’s mother Li Lai Ma pressed a buzzer and a nurse reviewed her son again. “The observations indicated he was extremely unwell,” Ms Mutch said. “The registrar recognised that he probably had sepsis and the treatment was adjusted.
“But this was not escalated to the on-call consultant. It should have been.”
Throughout her summary, Ms Mutch noted readings that could have been taken – including a blood sample and a radiometer reading, which is used to assess critically ill patients.
“This is a quick, easy way to get a snapshot of a person’s condition,” said Ms Mutch. “It is readily available to ward staff.
“The reading at 2.42am indicated that Pak was very unwell, but its significance was not recognised. A further reading was not obtained until 7.35am.”
A blood sample was taken at 4.40am, but the results were not available until ‘around 8am’, Ms Mutch said. “They showed that he was not improving and had severe sepsis,” she added.
At around 4.30am, Pak was reviewed by the registrar, who recognised he had septic shock. But the court heard the on-call consultant was not called until 6.15am and did not arrive until 7.15am.
“The consultant did provide advice over the phone, but it is unclear why there was a delay,” the coroner said.
Despite the intervention of multiple teams, Pak continued to deteriorate rapidly, Ms Mutch said. A post-mortem concluded he died from multi-organ dysfunction due to septic shock.
Ms Mutch said: “The family have asked me to consider attaching the word ‘neglect’ to my conclusion. This requires a gross failure to provide basic medical attention to someone in a dependent position, who can not provide it for themselves.
“I am satisfied that there were failings in Pak’s care – in particular, the failing to take regular radiometer readings; to escalate for clinical review and then consultant input; and the failure to take bloods. These are basic matters.
“I am satisfied that all of these failings, together, amount to a ‘gross failure’ and that these failures contributed to Pak’s death. I am therefore satisfied that the only conclusion I can record is one of natural causes contributed to by neglect.”
Ms Mutch added: “I am satisfied that Tameside have taken very significant steps since Pak’s death to deal with the issues in this case.”
She asked the chief executive of Salford Royal Hospital to write to her within 28 days to confirm arrangements were in place ‘to improve communications during patient transfers’.
Following the hearing, a spokesperson for Tameside and Glossop Integrated Care NHS Foundation Trust said: “We wish to offer our heartfelt condolences to the family during this extremely difficult time.
“The inquest has identified some missed opportunities in their son’s treatment. We are deeply sorry for this. We accept the coroner’s findings and will continue to make improvements to avoid a similar situation occurring in the future.”
Bosses said the trust has implemented ‘additional training on the management of paediatric sepsis’.