A delay in administering antibiotics to a three-month-old baby with sepsis equates to a “serious failure” by medical personnel, an investigation concluded.
Lewys Crawford, of Cardiff, died the day after being admitted to A&E at the University Hospital of Wales at high temperature in March last year.
The three-month-old baby was first seen at around 8.30pm on March 21, but was not given broad-spectrum antibiotics until 3:00 am the following day, an investigation was heard at the Coroner’s Court in Pontypridd.
A jury concluded that Lewys’ missed treatment with antibiotics before 11.30pm “contributed significantly” to his death.
Senior coroner Graeme Hughes summarized the evidence heard during Friday’s five-day survey.
Speaking later, his parents said it had been “horrible to everyone involved.”
Hughes said Lewys’ mother, Kirsty Link, said her son had been his “normal self” until around 4:00 pm on March 21 when he found out that he had a temperature.
He gave him some Calpol but took him to Cardiff A&E at about 8.15pm when his condition didn’t improve.
Mr. Hughes said the nurses observed that he had a rapid respiratory rate, heart rate and high temperature.
Dr. Jo Mower told the court that she examined Lewys at approximately 9.15pm.
Hughes said Dr. Mower said she rated Lewys as a “hot baby rather than a septic baby”, but agreed that this was the wrong diagnosis.
Hughes said Dr. Mower admitted that if she followed the septic risk guidelines, “she would have come to a different conclusion.”
According to her tests, Dr. Ifeoma Ujomu said she examined Lewys at 10.30pm and suspected a bacterial infection, but “did not suspect she had sepsis”. He accepted that this was an “error of judgment” on his part.
He accepted to know the NICE guidelines. He admitted that he should have given antibiotics at the first opportunity by any means possible.
Dr Ujomu reported to the jury that he saw Lewys again at around 12.30 the following day, at which point he had been cannulated and given fluids.
The jury heard that Lewys was not given broad-spectrum antibiotics until about 3:00 am on March 22nd.
He died at 11.10pm on the same day.
Lewys’ cause of death was recorded as meningococcal septicemia (group B).
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Hughes said the expert witness, Professor Parviz Habibi, told the jury if the antibiotics had been administered at any time until 11.30 pm with a balance of probability that Lewys would survive.
He added that it was only “possible” that Lewys would survive if the antibiotics were administered after 12.30pm.
After retiring to consider Friday afternoon, the jury returned the conclusions.
The jury foreman said: “Lewys is likely to be in the early stages of meningococcal disease when he was hospitalized for an accident and emergency at the University Hospital of Wales on March 21 at 8.15pm.”
The jury said “more opportunities were lost” to identify Lewys as a high risk of sepsis and a “failure to treat Lewys with antibiotics before 11.30pm”.
The jury found that it “contributed significantly” to his death.
The jury recorded a conclusion of death from natural causes contributed by negligence.
The team leader stated that a “serious error occurred until 11.30 pm on March 21, 2019 inclusive”.
Coroner Graeme Hughes said he would evaluate whether a report on preventing future deaths was appropriate in this case.
Speaking after the investigation, his parents Kirsty Link and Aidan Crawford released a statement saying: “A four-day investigation into the death of our son Lewys Ryan Aidan Crawford, who died on March 22, 2019 in the sun, ends today 13 weeks.
“This investigation was horrible for everyone involved and we heard evidence of serious shortages from the health board and its staff that led to Lewys’ death. Shortly after bringing Lewys to the emergency room, there were missed opportunities to give Lewys the life-saving treatment he so desperately needed.
“The jury found out today that there were serious failures that led to the delay in providing Lewys with basic antibiotic treatment. This treatment would have saved his life.
“This process was aimed at obtaining justice for Lewys and fortunately measures are being taken at the health council to ensure that what happened in Lewys does not happen again under any circumstances. We want to ensure that lessons have been learned and that no else the family has to go through what we went through with Lewys.
“Lewys will be forever missed and loved by us and the whole family and we will cherish all our memories of the short time we spent with him.”