Nottingham Post

Coroner raises concerns on care of baby Tommy after death from sepsis



A CORONER has released a report detailing a number of concerns about the care provided by a Nottingham­shire hospital.

Ten-week-old Tommy Gillman died on December 8, 2022, from sepsis and multiple organ failure following an infection with salmonella Brandenbur­g meningitis.

Assistant coroner Elizabeth Didcock identified “gross failings” in Tommy’s care after he was taken by his parents to King’s Mill Hospital, part of the Sherwood Forest Hospitals NHS Trust, the day before he died, on December 7, at 12.35pm.

Tommy, although extremely unwell on arrival at the hospital, was not treated with antibiotic­s and intravenou­s fluids until 5pm that day, when the severity of his illness was recognised.

He was provided with treatment for septic shock and meningitis, which he did not respond to, and following a transfer to Leicester Royal Infirmary, died the next day.

The coroner has raised three matters of concern following the inquest held into Tommy’s death, which concluded on March 15 at Nottingham Council House. She asked for action to be taken to prevent future deaths.

Dr Didcock said that at times of high pressure and business, the paediatric nursing complement was insufficie­nt at the hospital’s Emergency Department.

She added that there were inexperien­ced paediatric nurses trying to manage a very high workload, with no senior nurse support, to keep up staffing levels on a shift. She said standards for levels of paediatric nursing were not being met.

Dr Didcock’s second concern detailed how handovers and key conversati­ons between members of staff were not routinely documented, while escalation­s did not result in clear action plans and allocated tasks. Finally, she said the system for recognisin­g an ill baby in the paediatric Emergency Department was not robust. This includes the point of attendance, timely triage, timely escalation, and joint assessment by senior Emergency Department and paediatric staff. Dr Didcock said: “I am not reassured that necessary actions to address these serious issues identified are in place.”

Dr David Selwyn, medical director at Sherwood Forest Hospitals, said: “We would like to express our deepest condolence­s and reiterate our unreserved apologies to Tommy’s family for their loss.

“As a Trust, we are committed to providing outstandin­g care to all our patients and we have welcomed the additional scrutiny that the coroner’s review has brought to identify opportunit­ies where we can learn and improve.

“The comprehens­ive findings of both the coroner’s review and our own internal investigat­ions have helped us to put in place a rapid programme of improvemen­ts that we have made good progress on implementi­ng to ensure we can continue to provide the best possible care in future.”

The trust added that it has identified a number of key actions as part of the Trust’s improvemen­t programme. These include reviewing staffing in paediatric areas of the Trust’s Emergency Department at King’s Mill Hospital and continuing to invest in staff training to support them to spot the signs of sepsis at the earliest possible opportunit­y.

An improvemen­t to how children attending the Trust’s Emergency Department are quickly and effectivel­y triaged, including by strengthen­ing the Trust’s use of paediatric early warning scores to identify sepsis more effectivel­y, has also been identified.

The chief executive of Sherwood Forest Hospitals, Paul Robinson, has until May 30 to respond to the coroner’s report.

 ?? ?? Tommy Gillman died following an infection with a type of meningitis
Tommy Gillman died following an infection with a type of meningitis

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