Theodore Paul Cheetham-Serjent was taken to the hospital by his mum Paula as he had cold feet and hands, hot legs, diarrhoea and a temperature. He died hours after returning home from A&E
Image: Family Handout)
A five-year-old boy died of sepsis hours after being discharged from A&E with a “stomach bug”, an inquest heard.
Theodore Paul Cheetham-Serjent was taken to the hospital by his mum Paula as he had cold feet and hands, hot legs, diarrhoea and a temperature.
Trainee Dr Grace Olowonyo examined the boy – known as Theo – and gave a “presumptive diagnosis” of gastroenteritis, coroner Timothy Brennand said.
Theo was also given McDonald’s chicken nuggets as a “treat for being a brave boy in A&E”, the inquest at Bolton Coroners Court heard.
But when the family returned home and went to sleep, Theo began vomiting, so his mum called an ambulance.
When paramedics arrived, they gave Theo antibiotics because they suspected it was sepsis, according to the Manchester Evening News.
The boy was intubated, but by 8.20am on December 30, 2019, he had suffered a heart attack.
He was successfully resuscitated, but just half an hour later suffered a second cardiac arrest and failed to respond to further resuscitation.
Theo – who was described by his family as a “vibrant and intelligent” boy – was pronounced dead at 9.03am that day.
In court, Mr Brennand agreed with pathologist Dr Melanie Newbold’s conclusion that the cause of Theo’s death was septicaemia (neisseria meningitis Type B).
The coroner also mentioned concerns raised by the family in his conclusion.
He said: “It is my view and my finding that the decision and the presumptive diagnosis that was made at the first presentation by Dr Olowonyo was not unreasonable in the circumstances.
“It was, of course, as we now know, an entirely erroneous diagnosis, but each of the clinicians and as shown by a review by Dr Wayne Heaven, a consultant in emergency medicine, all [medics] believed that the diagnosis was appropriate, given Theo’s symptoms.”
Mr Brennand said Theo had markings and bruises on his legs, which doctors thought the boy may have sustained after falling from a bicycle.
The coroner said the markings were “worthy of further and more considered evaluation”, however he did not consider the treatment and response by doctors to be below standard.
Dr Olowony did not talk to more a senior colleague, did not as ask for a blood test and did not take a stool sample, all of which may have pointed to a correct diagnosis, the inquest heard.
However, other doctors giving evidence said they would have done the same as the junior medic.
Mr Brenand went on: “The reason that the decisions were made were all underpinned by her genuine and honest belief that she was calling it as she saw it, namely that she dealing with an individual who was suffering from gastroenteritis.
“I have to accept at face value that Dr Olowonyo, given her status as a GP trainee doctor, did her honest and noble best within the auspices and construct of her training and with the benefit of her experience simply called it as she saw it.
“The tragedy of course in this case is that in fact, but she would know it, it is likely on the balance of probabilities that at that time Theo was within the grip of a meningococcal infection that had not manifested itself with obvious symptoms.
“It’s very telling that the doctor, when she found out about the news, was simply shocked and could not face coming to work the following day, because of the enormity of her differential diagnosis.
“These are decisions that clinicians and families have to live with for the rest of their lives.”
But Mr Brennand said: “Where there is any doubt and room for doubt it is always safer and far more advisable to cross-check and ask of other more senior clinicians so that there is a confirmation in relation to the correctness of the differential diagnosis. This seems to me an exaltation in common sense.
“That didn’t happen in this case and the reason it didn’t happen was that Dr Olowonyo was convinced in her own mind that she had made the correct diagnosis.
“That is a decision which she will have to live with and consequences of which the family will have to endure for the remainder of their days.”
However, as part of his conclusion that Theo died of natural causes, the coroner said: “I do not feel that any of the family’s criticisms, issues and a quite proper sifting through the notes and evidence, asking themselves the question ‘what if’ amounted to a scenario where I could contend and establish that there has been a lack of care or neglect.”
Addressing the family, Mr Brennand said: “I pay tribute to you for your dignity, restraint, insight, concern and the motivation behind the questions that you’ve put.
“You have been strident, clear and unequivocal in simply wanting to make sure that there was no trick missed, no stone left unturned, nothing that either could or should’ve been considered that might’ve saved Theo.
“Nothing that we have said today can bring Theo back. For your loss, I’m truly sorry. In those five short years Theo has touched not just you as a family, but many other people.
“The sheer number of people who have come today to watch this to try to understand it and make some sense of this is tribute itself, a reflection of the type of young boy that he was.”