Jury finds baby who died with chickenpox “should not have been discharged” from Chesterfield Royal Hospital

Hunter Martin, aged six months, was sent home with his parents by staff at Chesterfield Royal Hospital (CRH) on March 4 last year.

The baby had been brought to the hospital with a high temperature and racing heart rate, having contracted chickenpox at home.

Two days after his discharge Hunter died at Sheffield Children’s Hospital, having developed sepsis and suffered three cardiac arrests.

During a week-long inquest at Chesterfield Coroners Court, jurors heard the baby was given paracetamol and ibuprofen on March 4 at CRH to bring his temperature down.

Later the same day – on the evening of March 4 – Hunter was discharged as his temperature and heart rate were now deemed to be within normal range.

However, giving its findings at the conclusion of the inquest on Monday, the jury noted “Hunter should not have been discharged”.

The jury foreman told the inquest: “If he had been kept in hospital it is likely he would have had relevant tests and been given intravenous antibiotics because there would have been high suspicion of sepsis and it is probable he would have been successfully treated.

"Guidance available to medical staff advises against the use of ibuprofen in chickenpox and this likely masked the true clinical picture.”

The inquest was told how, following Hunter’s discharge, he was found “drowsy” on the morning on March 5 by parents Alex Martin and Jade Smith and taken back to CRH.

After being diagnosed with septic shock and suspected pneumonia, Hunter was observed and considered to be stable throughout the afternoon.

However by the early hours of March 6 his condition had deteriorated, and this was consistently raised by an attending nurse, the jury noted.

Hunter was later transferred to Sheffield Children’s Hospital, having suffered a cardiac arrest. He died there on March 6.

The inquest was told how on March 5 while at CRH Hunter received 10 times the recommended dose of antibiotic drug Clyndamycin on five separate occasions.

This was despite the requirement for twe nurses to independently check the dose each time it was administered.

However, the jury noted: “On the evidence it cannot be established that the over-administration probably more than minimally contributed to his (Hunter’s) death.”

Coroner Peter Nieto concluded that Hunter died due to an invasive group A streptococcal bacterial infection.

He added: “Hunter’s death was contributed to by the decision to discharge him from hospital on the evening of March 4, 2023.”

During the inquest Hunter’s mum Jade Smith described “textbook baby” Hunter as her “bonny blue-eyed angel” who had an “infectious laugh that would cheer anyone up”.

She described how during the evening of Sunday March 5 a nurse caring for Hunter “seemed a bit concerned” but she felt the nurse’s concerns had been “disregarded because she wasn’t a doctor”.

Speaking about the care Hunter received, she said: “I don’t believe that Hunter should have been discharged from hospital on the Saturday.

"If he had a blood test or a swab at the time this could have shown that he had an infection and possibly picked up the sepsis or (Group A streptococcus).

"I’m a big believer that a child’s parents know them best, so they should be listened to when it comes to the care of their child."

In a statement read out to the inquest Chesterfield Royal Hospital NHS Foundation Trust (CRH) admitted several mistakes concerning Hunter’s care.

The Trust added that, had the bacterial infection been treated on March 4, the baby would have survived.

CRH accepted in the statement that “with hindsight” there were later “missed opportunities” to spot worsening features of sepsis in Hunter’s case and transfer him to tertiary intensive care at CRH.

The Trust offered a “profound” apology to Hunter’s parents over the overdose of antibiotic drug Clyndamycin, saying “it should not have happened”.

It added that improvements had been identified since at the hospital which needed to be carried out.