Salford<\/a> Royal Infirmary, where he had been diagnosed with pneumonia.<\/p>\nHis condition worsened through the night and despite repeated medical intervention he went into cardiac arrest just before 9:30am and died just before 10am after three rounds of CPR.<\/p>\n
Senior area coroner Alison Mutch began proceedings by reading a statement from Pak’s mother Li Lai Ma. The parents, who were spoken to via a Cantonese interpreter throughout proceedings, left the room while the distressing account was read out.<\/p>\n
“Pak was a healthy, joyful baby who brought immense happiness to the family,” his mother said in her statement.<\/p>\n
“He was a cheerful, talkative and intelligent child who loved animals and playing with Spiderman toys.”<\/p>\n
“We moved to the UK 12 months before his death and he adapted well. He was all a parent could hope for – thriving and full of life.”<\/p>\n
Ms Mutch then read statements from Pak\u2019s GP, the 111 operator who had triaged the family over the phone, the radiologist who had taken an x-ray of Pak at Salford Royal and the NWAS driver who had transferred the family to Tameside, before turning to the facts of the post-mortem.<\/p>\n
![](\"https:\/\/www.europesays.com\/uk\/wp-content\/uploads\/2025\/06\/0_South-Manchester-Coroners-Court-Stockport-1JPG.jpg\")
(Image: MEN Media)<\/p>\n
The examination found that Pak had died of multi-organ dysfunction caused by septic shock, itself brought on by invasive pneumococcal pneumonia. There was evidence of fluid in his right lung and in his chest.<\/p>\n
Pak had been suffering with stomach pains, vomiting and a high temperature for several days when his parents first brought him to Salford Royal Infirmary on November 30 2023.<\/p>\n
That evening doctors diagnosed him with an upper respiratory tract infection and gastroenteritis, and advised Pak’s parents to continue treating him at home with ibuprofen and Calpol.<\/p>\n
If he did not improve after five days, the family was told to return to hospital – but Li Lai Ma said that no antibiotics were administered, nor were blood samples taken.<\/p>\n
“At that moment I felt that something was not right. My fears and concerns were dismissed,\u201d she alleged.<\/p>\n
At home, Pak’s condition did not improve, as he continued to vomit and his appetite ‘disappeared’. The family returned to Salford Royal A&E in the early hours of December 4 with Pak extremely pale and barely managing to drink water.<\/p>\n
Upon arrival nurses recorded his blood oxygen, blood pressure and temperature, and an x-ray was ordered. He was periodically reviewed throughout the night.<\/p>\n
At 8:30am he was reviewed by Dr Anna Rennie, a consultant in paediatric and emergency medicine at Salford Royal.<\/p>\n
In her statement she noted that Pak had no rash and presented normal levels of consciousness, but added that he seemed tired and was \u2018working harder than normal\u2019 to breathe on his right-hand side.<\/p>\n
Reviewing the x-ray taken overnight, Dr Rennie diagnosed Pak with right-sided pneumonia, and placed him on intravenous antibiotics and a rehydration treatment.<\/p>\n
But she explained to the court that, as Salford Royal does not have any paediatric ward beds that can accommodate children for more than 24 hours, Pak was transferred to the nearest available bed which was at Tameside Hospital.<\/p>\n
![](\"https:\/\/www.europesays.com\/uk\/wp-content\/uploads\/2025\/06\/0_ABNM_MEN_21122022_AMBULANCE_STRIKE_44695JPG.jpg\")
Tameside Hospital (Image: Manchester Evening News)<\/p>\n
As Pak\u2019s level of risk was assessed as yellow, he did not receive IV treatment during the transfer nor were any medical personnel present – but Dr Rennie deemed that this would be safe for a half-hour journey.<\/p>\n
\u201cWhat was your overall impression of him, looking back?\u201d asked the coroner.<\/p>\n
\u201cI did not feel he was septic, but I was concerned about his risk of deterioration, and that includes sepsis,\u201d Dr Rennie replied. \u201cAny child with pneumonia is at risk of that.\u201d<\/p>\n
She added that a \u2018full set\u2019 of notes was sent over with every transferred patient and that a verbal \u2018clinician to clinician\u2019 conversation took place in which she informed staff at Tameside hospital of Pak\u2019s history and any concerns she had.<\/p>\n
\u201cIt was expressly mentioned that I felt concerned about him,\u201d she continued. \u201cany clinician with sufficient training will recognise that a child with pneumonia is at risk of sepsis.\u201d<\/p>\n
\u201cWhat was the name of the person you spoke to?\u201d the coroner asked.<\/p>\n
\u201cUnfortunately I didn\u2019t get their name,\u201d Dr Rennie answered. \u201cThat is something I have reflected on following this case.\u201d<\/p>\n
The family were then transferred to Tameside Hospital, arriving at around 2pm on December 4. Registered paediatric nurse and ward manager Holly Martin, who did not come into contact with Pak until her shift began on the morning of December 5, detailed in her report how nurses had taken observations of Pak\u2019s progress throughout the night.<\/p>\n
The court heard how he continued to receive antibiotics and hydrating fluids via an IV, but his condition continued to worsen.<\/p>\n
His heart and breathing rate continued to climb, while he remained by turns drowsy and agitated, not responding to light shone in his eyes.<\/p>\n
Coroner Mutch asked Ms Martin about the observations the nurses took, which are used to calculate the PEWS score, a paediatric early warning system used to monitor deterioration in patients.<\/p>\n
Ms Martin agreed that some of the notes were incomplete. \u201cHow do you create a PEWS score when some observations, such as blood pressure, are not recorded?\u201d the coroner asked.<\/p>\n
\u201cThe old scoring system did not require all these elements in order to create a score,\u201d Ms Martin replied. \u201cWe have since moved to a different system.\u201d<\/p>\n
There was also discussion of the \u2018sepsis bundle\u2019, a set of treatments and checks designed to reduce sepsis mortality.<\/p>\n
\u201cWas the bundle used in Pak\u2019s case? \u201d the coroner asked. \u201cI do not believe so, based on the notes,\u201d came the reply.<\/p>\n
\u201cShould it not have been, when his PEWS score went from 2 to 5 between 2:30 and 4am? The doctor notes suggest that around 4:30am there was a clinical review from the registrar \u2013 is that what the nursing notes suggest?\u201d Ms Mutch continued.<\/p>\n
\u201cThey show that there was further medical review but it’s not clear at what time. It\u2019s not in the documents,\u201d Ms Martin replied.<\/p>\n
Counsel for the family Louise Green focused on the frequency of the nurses\u2019 observations. \u201cDo you agree that it looks like no nursing observations took place between 8pm and 12:30am?\u201d she asked Ms Martin.<\/p>\n
\u201cThat is what the documents would appear to show,\u201d she replied.<\/p>\n
![](\"https:\/\/www.europesays.com\/uk\/wp-content\/uploads\/2025\/06\/0_Gary-OakleyManchester-Evening-News.jpg\")
Stockport Coroner’s Court(Image: Gary Oakley\/Manchester Evening News)<\/p>\n
At around 6:30am on December 5 Pak was moved to the high-care bed in the paediatric unit. NWTS (North West Paediatric Transport Service) and the on-call paediatric consultant, Dr Mazen Haider, were called in.<\/p>\n
Dr Haider had began his shift at 5pm on December 4 and went home at 8pm, remaining on-call overnight until 9am the following day.<\/p>\n
Overnight he had discussed Pak with the hospital registrar, who told him he had become less responsive and was now vomiting a dark brown substance.<\/p>\n
\u201cWhat was it that caused you to recognise that Pak was in septic shock?\u201d the coroner asked.<\/p>\n
\u201cThe repeated administering of fluids and the repeated tachycardia (heart rate over 100bpm),\u201d he replied. \u201cThe registrar had taken several steps to manage his condition.\u201d<\/p>\n
Dr Haider stressed that, when he arrived for his shift the previous evening, none of Pak\u2019s observations were consistent with sepsis. \u201cBefore I left I asked the staff if they had concerns about anyone \u2013 and no-one did at that time.\u201d<\/p>\n
His notes clarified that Pak was treated throughout the night but it did not appear to be having an effect, though there was no significant deterioration until around 5:30am.<\/p>\n
\u201cYou did not get the phone call until 45 minutes later though,\u201d said the coroner. \u201cAt that point it was quite clear that it was septic shock \u2013 it is now a race against the clock, is it not?\u201d \u201cYes,\u201d Dr Haider agreed.<\/p>\n
But he also spoke of the difficulty in diagnosing sepsis. \u201cDiscoloured vomit could be stress,\u201d he said. \u201cAnd any child who has vomited will be looking pale.\u201d<\/p>\n
\u201cPneumonia is common but the sepsis progression is rare, and progression into septic shock even rarer,\u201d he added.<\/p>\n
Dr Haidar arrived at the hospital at around 7:15 am when Pak was given an oxygen mask to help him breathe. He was intubated and given adrenaline but he entered cardiac arrest.<\/p>\n
In her statement read out at the start of proceedings, Pak\u2019s mother Li Lai Ma said she \u201cstrongly felt there were missed opportunities\u201d for staff to help Pak and \u201cpossibly save his life.\u201d<\/p>\n
\u201cWhen he was given an oxygen mask, he was clearly distressed and weak, but was trying to speak and say something,\u201d she said.<\/p>\n
\u201cI will never forget the image of him struggling to speak while they covered his mouth again and again. That moment is burned into my mind.\u201d<\/p>\n
\u201cI told him to fight and be strong so he could come home with us. After the final cardiac arrest I started shouting at them to keep going but the doctor said he was gone.<\/p>\n
\u201cWe were both just devastated. We all said goodbye and just held each other. Our healthy, happy child, it felt impossible to understand.\u201d<\/p>\n
\u201cMy son was misdiagnosed and critical opportunities to save his life were missed. I strongly believe that had a consultant been informed earlier, his death could have been prevented.<\/p>\n
\u201cIt was a serious infection but they did not escalate his care and did not listen when I told them something was wrong.<\/p>\n
\u201cAll I want is for the real reason for his death to be known and for the court to look into the treatment from the staff involved. They did not take their responsibility seriously enough.\u201d<\/p>\n
Like the other witnesses, Dr Haider offered his \u2018deepest condolences\u2019 to the family at the end of his statement. \u201cI want them to know that we did all we could to save him,\u201d he said.<\/p>\n
The inquest continues.<\/p>\n","protected":false},"excerpt":{"rendered":"\u201cI told him to fight and be strong so he could come home with us\u201d 06:55, 18 Jun…\n","protected":false},"author":2,"featured_media":193732,"comment_status":"","ping_status":"","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[8813],"tags":[748,393,4884,2465,1832,1026,59729,16,15],"class_list":{"0":"post-193731","1":"post","2":"type-post","3":"status-publish","4":"format-standard","5":"has-post-thumbnail","7":"category-manchester","8":"tag-britain","9":"tag-england","10":"tag-great-britain","11":"tag-manchester","12":"tag-salford-royal-hospital","13":"tag-tameside","14":"tag-tameside-hospital","15":"tag-uk","16":"tag-united-kingdom"},"share_on_mastodon":{"url":"https:\/\/pubeurope.com\/@uk\/114703034264038337","error":""},"_links":{"self":[{"href":"https:\/\/www.europesays.com\/uk\/wp-json\/wp\/v2\/posts\/193731","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.europesays.com\/uk\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.europesays.com\/uk\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.europesays.com\/uk\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.europesays.com\/uk\/wp-json\/wp\/v2\/comments?post=193731"}],"version-history":[{"count":0,"href":"https:\/\/www.europesays.com\/uk\/wp-json\/wp\/v2\/posts\/193731\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.europesays.com\/uk\/wp-json\/wp\/v2\/media\/193732"}],"wp:attachment":[{"href":"https:\/\/www.europesays.com\/uk\/wp-json\/wp\/v2\/media?parent=193731"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.europesays.com\/uk\/wp-json\/wp\/v2\/categories?post=193731"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.europesays.com\/uk\/wp-json\/wp\/v2\/tags?post=193731"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}
![](\"https:\/\/www.europesays.com\/uk\/wp-content\/uploads\/2025\/06\/0_MEN_Stockport-Coroners-Court.jpg\")
(Image: Men Media)<\/p>\n