Chesterfield Royal Hospital could have "reversed" three-year-old's septic shock but did not follow "guidelines", inquest hears

Oscar Neillings died at Chesterfield Royal Hospital (CRH) on November 8 2023, having contracted sepsis. An inquest heard on Friday that the boy was rushed to CRH in an ambulance after showing clear signs of the condition.

After arriving at the hospital at around 10.30am, two-and-a-half hours passed before he was given antibiotics by which time his symptoms had become fatal and he suffered a cardiac arrest – dying at 5.30pm. Oscar died from 1A sepsis following bronchopneumonia and invasive strep A infection.

A consultant paediatrician, Dr Nelly Ninis of London’ St Mary’s Hospital, told jurors at Chesterfield Coroners Court sepsis was “not recognised” in the infant by staff at CRH, adding that no-one at the hospital really “owned” Oscar’s care – which she described as “fragmented”.

She said: “Sometimes people cannot recognise but do the right thing. But in this case I don’t think they acted in accordance with national guidelines (for treating sepsis).”

On November 5 Oscar was diagnosed with a viral upper respiratory infection by an out-of-hours GP at Chesterfield’s Ashgate Manor and his parents were told he would not need to be hospitalised. During a further out-of hours consultation just before 11pm on November 7 another GP working “in the background of a viral upper respiratory infection” noted “nothing of serious concern” requiring “red flag life support mode.”

However, the following morning Paramedic Mark Amsbro was called to the family’s GP practice where he encountered Oscar “clutching to” mum Stephanie Neillings while “quiet and subdued”, appearing “very unwell”.

By this time Oscar’s heart rate was “extremely high”, his respiratory rate was “elevated” and he had a “dry nappy” showing he was not passing urine and had cold limbs – all signs of sepsis.

The court was told how there was evidence that Oscar was in septic shock the morning of his transfer to hospital. Paediatrician Dr Ninis said that under National Institute for Clinical Excellence sepsis protocols, a high dose of antibiotics and "rapid infusions of fluid” were needed within the first hour to reverse septic shock.

Oscar did not receive antibiotics until 12.54pm and only 10ml of fluid – however he required at least 60ml. Guidelines also recommended ventilation and an entire intensive care “team” within the first hour of the symptoms appearing, said Dr Ninis.

She added: “There was no data left that was required. If you were following protocol you would now be calling everyone available to help you. It’s time critical. You need to be calling your regional intensive care unit and get the child on a ventilator – you need a lot of people.”

Dr Ninis said if protocols had been followed at CRH on November 8, Oscar would not have died that afternoon. She said: “If he had done all the sepsis protocols he wouldn’t have died that day. He had a significant risk of death – but all the conditions were reversible and treatable. Intensive care units know what to do – they do this often.”

Jurors were told that at around 2pm a nurse finally called an anaesthetist after finding Oscar “very unwell”, however he later suffered a cardiac arrest before his death several hours later.

Dr Ninis said Group A strep was “unpredictable” and “sometimes children die”. However she added: “I don’t think he would have died that afternoon. There is no reason to suspect that he would not have responded. You can reverse the shock.

“I think he would have responded to fluids. He could have survived, if he had followed standard recovery for children with sepsis. I just can’t be clear he would have.”

The inquest heard prior to hospitalisation two out-of-hours GPs failed to diagnose sepsis despite Oscar’s mother Stephanie Neillings seeing a "white pustule" on the boy’s tonsils after he complained of a sore throat.

On November 5 Oscar was diagnosed with a viral upper respiratory infection by out-of-hours GP Dr Oakley at Chesterfield’s Ashgate Manor and his parents were told he would not need to be hospitalised.

When his condition worsened with abdominal pain and “gulping” his father Mark Neillings returned him to the out-of-hours GP service on November 7 and he was seen by Dr Simon Possee just before 11pm.

Giving evidence Dr Possee said he had qualified in April 2023 and worked out-of-hours shifts for DHU Healthcare. Confirming that Oscar’s medical notes contained a diagnosis of viral upper respiratory infection, Dr Possee was asked if that had “informed” his own consultation.

He said: “I would always judge something on what I’m seeing on front of me. I wouldn’t take someone else’s diagnosis and a copy and paste approach. The 111 call was about abdominal pain – in the background of a viral upper respiratory infection.

“There was nothing of serious concern that would make me go into red flag life support mode. He had a bit of a cough, I don’t remember anything immediate that would make me go oh no, there’s something wrong "Dad said he was doing a gulping sort of thing. I attributed it to large tonsils making it more difficult – no fast breathing to suggest respiratory distress at that time."

Dr Possee confirmed he believed Oscar’s symptoms on November 7 were a progression of the illness Dr Oakley had diagnosed and believed the virus had triggered the infection. He added: “Body aches and abdominal pain can be a feature”.

He said: “The heart rate was the upper end of normal. I didn’t make anything of that in particular. Respiratory was normal. He was alert during the consultation. I didn’t have any great concerns. I felt like I had enough information and took my time – a diagnosis of an ongoing viral issue. I attributed this as all part of one illness rather than a whole new issue.”

By the time of the November 7 consultation Oscar had symptoms of strep pneumonia including abdominal pain, the inquest heard. Coroner Julie Mitchell asked the doctor if he had noticed any signs of pneumonia. He replied: "I wasn’t suspicious of pneumonia. There were no additional sounds like crackles or wheezes.”

The coroner asked Dr Possee if he was aware abdominal pain was a potential symptom of Group A strep or pneumonia, to which he replied: “At time it would not be at the front of my brain”, adding he had “never seen” someone presenting with abdominal pain with Group A strep or pneumonia, including children.

Asked if his view of abdominal pain as an indication of Group A strep or pneumonia had now changed, the GP said: “I’ve thought about this a lot and have learned Group a strep and pneumonia can present as abdominal pain.

“I know the outcome and its not something I believe is common – it’s a rare presentation but it clearly must exist and it’s something I’ve learned from. I was not aware at the time.”

Asked whether he should have requested a chest X-ray at the time or escalated Oscar’s case to scent to hospital A&E, the doctor replied: “I made a clinical judgement at that time – I didn’t feel the need to escalate his care to A&E.

“If his vital signs were worse, higher heart rate, lower oxygen saturation and breathing very fast...all of these sort of things would make me concerned that I can’t send him home and he needs monitoring in hospital.”

After the consultation Dr Possee confirmed he passed on “safety netting” advice to Oscar’s father Mark, such as signs of continuing abdominal pain, fever and Stridor (an audible noise while breathing suggesting an obstruction in the upper airway). Mr Neillings was advised to continue giving the child Calpol and seek reassessment if symptoms changed.

Dr Possee said he was aware at the time of the consultation that Group A Strep was on the increase, having received “learning emails” about it while still training in 2022.

However, when asked if he had ever treated “strep pneumonia” in children the doctor said: “I don’t recall if I have encountered strep pneumonia in a child before this.” Asked if he felt opportunities in Oscar’s care had been missed at the time, Dr Possee said: “I’ve thought about this many times and honestly do not think it would be standard for me to escalate the care at that point.”

Addressing Oscar’s parents during the hearing, Dr Possee said: "I’m sorry for the parents, I have young children and no parent should have to go through this – I am sorry”.

The inquest continues.