Report by Katie Cole
A coroner says he will write to the Health Secretary urging him to push forward with a sepsis review and to express concern around how antibiotics are administered following the death of a four-year-old boy from Wearside.
Sheldon Farnell, from Houghton-le-Spring, died from sepsis in November 2018, the day after being discharged from Sunderland Royal Hospital.
Today, a jury ruled the South Tyneside and Sunderland NHS Trust did not contribute to his death by neglect. The trust has apologised to Sheldon’s family for ‘shortcomings’ in his care.
An inquest heard there were four missed opportunities to give him antibiotics, he was sent home before results came back and if the hospital had the right phone number for his family he could have survived.
Four-year-old Sheldon was taken to the hospital on November 23, 2018, with symptoms including vomiting, feeling sleepy and suffering headaches.
An inquest heard tests were carried out and on Sunday November 25, before a definitive result came back he was discharged after his condition appeared to be improving.
A short time later, the tests revealed Sheldon did have a bacteria that can cause sepsis in his blood and the hospital tried to contact his family nine times on three different phone numbers so antibiotics could be administered.
The inquest heard staff discussed asking the police to contact Sheldon’s family but that didn’t happen and instead it was agreed the following day the hospital would contact his GP surgery.
In the early hours of the following morning, November 26, 2018, Sheldon was brought back to Sunderland Royal Hospital suffering from septic shock. He died a short time later.
In a statement read to the court, Sheldon’s mother Katrina said her heart and life was shattered.
“On the last day of his short life my son begged me not to let him die, no four year old should even know about death, my baby boy knew he was facing it.
"My heart is broken, there is a massive hole in my life that will never be filled. No parents should have to bury their child. I wouldn’t wish it on my worst enemy. My son died in my arms, my arms still ache to hold him again.
"My last memory of my son is kissing him goodbye for the last time as he lay in his tiny paw patrol coffin, my baby. My Sheldon was my world and my world is a much lonelier, darker place without him in it.“
Dr Geoffrey Lawson, who was a consultant paediatrician at Sunderland Royal Hospital, told the inquest his decision to discharge Sheldon from hospital was his lifelong regret.
Dr Niresha Sirinanda, a senior paediatric trainee at the time had tried to contact Sheldon’s family about bringing him back for antibiotics. She told the inquest "I am over cautious about everything now after this incident. It has affected so much, not just professionally but personally. I repeatedly reflect on it, what could or should I have done differently."
Dr Paul McAndrew, Deputy Medical Director at South Tyneside and Sunderland NHS Foundation Trust said:
“On behalf of South Tyneside and Sunderland NHS Foundation Trust, I would like to once again offer our condolences to Sheldon’s family and apologise unreservedly on behalf of the Trust for the shortcomings in the care Sheldon received.
“There are no words to adequately express the regret we have in the tragic loss of young Sheldon on the morning of Monday 26th November 2018. Everyone involved in Sheldon’s care has been deeply affected by his death.
“The complexity of recognising Sepsis in children is a major challenge. We continue to undertake widespread education of our staff about the recognition and management of Sepsis. We have also made important changes should we ever need to recall any child to hospital in future.
“As recognised by the independent paediatric expert, Dr Ninis, the Trust has taken Sheldon’s death very seriously and there has been comprehensive review of processes and policies in line with national guidance. There has been, and will continue to be, much learning from this tragedy.
“There is nothing I can say to Sheldon’s family that will ever ease their pain, but I do want to reassure them, once again, of the steps we have taken to correct the things which went so tragically wrong for Sheldon.”