Mum says little boy 'didn't want to leave hospital' as she described final painful hours of her son's life
The mum of a four-year-old boy who died of overwhelming sepsis said he didn’t want to leave hospital.
Sheldon Gary Farnell died on Monday, November 26 2018, in the arms of his mum and grandmother a matter of hours after he was discharged from Sunderland Royal Hospital, an inquest into the youngster’s death has heard.
On the final day of evidence at the inquest in Durham’s Redhills, the jury heard how Sheldon’s mum Katrina Farnell, known as Katrina Keegan, says she asked for blood test results – which she was told had come back clear – and how her little boy’s condition did not improve in hospital.
She described the pain he was in and how his condition continued to worsen at home.
The inquest heard that on arrival at the hospital’s paediatric emergency department on the evening of Friday, November 23, Katrina’s partner, Holly Keegan, checked Sheldon in and was asked if the current contact numbers were up to date.
Holly checked with Katrina, who was cradling her ill child in her arms, who said they were updated when they attended the Niall Quinn Centre in the weeks prior to his death.
The family say they were never asked again for any contact details and were not told they would be receiving a call with updates in regards to test results. An investigation by the trust found all three numbers on file were no longer in use.
Talking about the early hours of Saturday morning after Sheldon was admitted, Katrina’s partner Holly Keegan, told the jury: "We were informed that the blood test results would be back in about an hour but because we hadn’t heard anything we kept going back to the nurses’ station all through the night and asking if the blood results were back.
"On numerous occasions we were told no and on the final one we were told ‘yes they have come back and we think they are all clear and everything is OK’.”
Later adding: "They never informed us about anything, we asked about blood results but we were never informed that there was any problem with them at all. All we heard was that they think the test results were okay, not that one had come back and could have been a contaminant or anything like that. There was no mention of CRP, no mention of streptococcus – nothing.
"We were told that it was a bad virus and it would get worse before it got better."
Katrina described in her statement, which was read out by senior coroner Derek Winter, how throughout his stay in hospital Sheldon was vomiting and had diarrhoea, was hot to touch and sensitive to light. He also couldn’t walk on his own and complained of pain throughout his entire body.
Talking about the day he was discharged, Katrina, of Houghton, said: “My mother was very concerned that Sheldon was being discharged home. I was also very concerned that Sheldon had told me that his arm and back were hurting and he looked worse than he did when he went into hospital. He still felt hot to the touch and his colour was still as he had been when they first attended.
"He was also distressed and told me and my mam that the did not want to go home. I understand that my mam and dad spoke to the nurse and asked for a second opinion as to whether it was really safe for us all to go home.”
Doctors gave evidence to say Sheldon’s condition improved during his hospital stay and he appeared ‘clinically well’.
The jury heard how on arriving home Sheldon still couldn’t walk and wouldn’t eat, complained of pain and bright light and he continued to suffer from vomiting and diarrhoea.
In the early hours of the Monday morning, grandmother Nicola Farnell and Katrina brought Sheldon back into hospital – where doctors say he was in septic shock.
In her statement, Nicola said: “We were invited to go to be with Sheldon in the treatment room. We arrived at the treatment room when Sheldon was alive and he died in mine and Katrina’s arms, and Gary (Sheldon’s grandfather) was by the bedside.”
The court heard how a police investigation into the possibility of gross negligence manslaughter was carried out and found no criminality.
Dr Paul McAndrew, Deputy Medical Director at South Tyneside and Sunderland NHS Foundation Trust, also gave evidence during the hearing on Wednesday, March 17, and highlighted the recommendations following an internal investigation by the trust into Sheldon’s death.
The five recommendations from his report, all of which have been completed, include changes around the way contact details are taken and checked at arrival and discharge; formalised escalation arrangements when staff are unable to contact a patient requiring further treatment; to prioritise identification of suspected strep urgently within blood cultures, and finally laboratory staff to actively communicate with medical microbiologists when strep pyogenes are isolated in blood cultures.
Earlier in the day, the inquest heard evidence from a another expert witness, paediatrician Dr Mark Anderson, who disagreed with Dr Nelly Ninis’ report that hospital staff missed four opportunities to start antibiotics.
He highlighted that following the lumber puncture he would have suggested antibiotics be started but by that morning where it appeared Sheldon clinically improved that he agreed with Dr Geoffery Lawon’s decision not to – saying the tragedy of the case falls to the inability to bring Sheldon back to hospital for antibiotics.
Dr Anderson said: "That’s the tragedy of this case, had it not been for that we wouldn’t be having this conversation, we wouldn’t be having this report.
"Had they been able to contact Sheldon’s family at the time then I sincerely doubt we would be sitting here having this conversation.
"Reflecting on that in hindsight because this would be the time where antibiotics could be started and would have made a difference and that is the tragedy here.”
He agreed that no harm would have come to Sheldon if he were given antibiotics.
The inquest continues.