A coroner has highlighted multiple “serious missed opportunities” by staff at a hospital following a baby boy’s tragic death.
Tommy Gillman, from Coddington, died at just 10 weeks old, on December 8, 2022, as a result of salmonella Brandenburg meningitis infection.
He died at Leicester Royal Infirmary where he was transferred to the day before he died, having undergone most of his medical treatment at King’s Mill Hospital.
Dr Elizabeth Didcock, assistant coroner for Nottingham and Nottinghamshire concluded an inquest into the baby's death at Nottingham Council House last Friday, March 15.
The coroner expressed numerous concerns regarding Tommy’s assessment and the time in which it took King’s Mill Hospital to provide him with medical treatment.
The inquest was informed that Tommy had an initial diagnosis of neonatal Strep B meningitis when he was born, which was recognised and treated promptly with the correct choice of antibiotics. Tommy then contracted bronchiolitis at the start of November 2022, and he was also investigated for sepsis.
Tommy was diagnosed with meningitis and provided with a three-week course of antibiotics.
This assessment and treatment were based on general advice for meningitis in children, as well as for salmonella infections.
Dr Didcock outlined that there is no salmonella meningitis-specific medical or national guidance. She said: “I find that the trust appropriately made a referral to the UK Health Security Agency, and that this team investigated for any other cases of salmonella around the area, and also considered possible sources of infection, though unfortunately neither the source nor any additional cases were found.”
Tommy’s parents, Tamzin Myers and Charlie Gillman, took him to A&E at King’s Mill Hospital at 12.35pm on December 7 where he displayed signs of sepsis.
However, when he arrived at the Hospital he wasn’t recognised as being a very unwell baby.
The reasoning for this assessment is not clear and the triage assessment, which the Coroner deemed to be inadequate, was delayed until just under an hour later.
The Inquest was told that the lack of recognition of how ill Tommy was and of the need for urgent medical treatment led to a lack of appropriate escalation to a senior doctor.
The severity of Tommy’s illness was recognised at 4.30pm, at which time he was given prompt treatment for septic shock and meningitis.
However, Tommy did not respond to the treatment and passed away the next day, after he had been transferred to Leicester Royal Infirmary.
The Coroner further noted that she would be issuing a Prevention of Future Deaths report to Sherwood Hospitals NHS Foundation Trust, which runs King’s Mill Hospital.
Dr Didcock said that the Trust has introduced changes following Tommy’s death, specifically to the paediatric early warning score electronic system, which she welcomed.
Despite this, Dr Didcock stated that she is still concerned with respect to how handovers and key conversations are carried out between staff members, especially during times of busyness, at the hospital.
She added: “I wish to extend my sincere condolences to the family and friends of Tommy, to his parents, to his grandparents, and to all who knew him.
“I am so sorry for your loss.”
Both of Tommy's parents as well as his grandparents and family friends, attended the Inquest conclusion.
The mother, Tamzin Myers, said: “We want everyone to remember the bright and smiley Tommy. We may have only had 10 weeks with him but they were the best 10 weeks of our lives.
“He showed us what being strong really is, so we need to be strong for him during this difficult time of our lives. As much as the inquest has been incredibly difficult, we are relieved that we finally have some answers as to what happened with Tommy.
“We hope that no other child has to go through what Tommy did, and now after the inquest we can finally have time to grieve for Tommy.”
Dr David Selwyn, medical director for Sherwood Forest Hospitals, said: “I would like to express my deepest condolences to Tommy’s family and offer them an unreserved apology at what we know will be an incredibly difficult time for them.
“As a Trust, we are committed to providing outstanding care to all our patients and the issues identified in this case fall well below the standards that people should rightfully expect from their local hospitals.
“We have welcomed the thorough review of this case as a vital opportunity to identify those areas where we must learn and improve to ensure we can provide the best possible care in future.”
Julie Hardy, partner at a medical negligence team, assisted the family during the Inquest process.
Barrister, Thomas Herbert of Ropewalk Chambers represented the family during the inquest.
Julie said: “Tamzin and Charlie were devoted parents to Tommy throughout his short life. No parent should have to attend an inquest into the loss of their child, and I have been constantly impressed with their dignity throughout this this experience.
“The coroner highlighted numerous missed opportunities to recognise that Tommy was so unwell, and to provide prompt assessment and treatment. She described these as gross failings.
“Although some changes have been made at the hospital, the coroner still had concerns about the safety of the paediatric emergency department at King’s Mill Hospital. Importantly the Coroner has indicated that she is issuing a Prevention of Future Deaths letter which will be sent to the Trust’s chief executive and to the Chief Coroner.
“This will set out her concerns and the Trust will have to provide a response to the coroner to explain what steps they will take to ensure that babies and children in their care will be safe in the future. While sadly these findings will not change the tragic loss the family have experienced, they are pleased that the coroner has investigated the circumstances of Tommy’s treatment so thoroughly.
“The family now have answers to many of their questions and I hope that this will help with their healing. It is important that lessons are learnt to avoid a repeat of these tragic events.”
