Mikey James Hornby · Prevention of Future Deaths report

On the 11th April 2014 an investigation into the death of Mikey James Hornby dob 31st March 2014 was started by the Coroner for Cheshire and subsequently transferred to me. The investigation concluded on the 12th December 2014 and the conclusion was one of Natural Causes contributed to by neglect. The medical cause of death was 1(a) E-Coli Neonatal Sepsis and meningitis

Mikey and his mother were discharged from hospital after his birth at around 15.00 hours on the 1st April 2014. From the outset he was a fussy eater. On the 6th April he attended the hospital for his ‘heel-prick’ test and whilst there it was brought to the attention of the staff that his umbilical-cord clip was ‘digging into his tummy’. The nurse advised that he should be seen by his GP. There were no available appointments so his father took him to the OOH GP service at 22.30 hours that night. They attended at the OOH surgery at the hospital and Mikey was seen by a doctor straight away who prescribed Fucidin Cream. On the 10th April at approximately 21.00 hours Mikey’s breathing became strange and he was taken to the OOH service where he was examined by the doctor who diagnosed a throat virus and prescribed “Paracetamol”. By the time the consultation had ended the hospital pharmacy, and all other rooms to the parents of Mikey, was closed for the night. Mikey was again taken home and placed in his Moses basket. At 05.15 hours the next morning he was found lifeless in his basket. He was rushed to hospital but could not be saved.

1. On the first attendance at the OOH service, the attending staff having seen the infected umbilical cord, did not immediately send Mikey to the Hospital (as would have been the correct procedure according to the Consultant Lead Paediatrician who gave evidence to me.)

2. On the second attendance the doctor failed to appreciate the seriousness of the situation and at 10.45 at night sent the child home with a prescription for analgesia (which could not be filled until the following day in any event). The Consultant Paediatrician gave evidence to me “that there was a very high probability that he would have survived” had he been sent to the hospital at this time as he could and would have been administered an intra-venous anti-biotic.

3. If there is any realistic possibility of the condition being meningitis, the child should have been immediately admitted to the hospital.

4. The GP covering the surgery that night indicated that they do not have the facility to take a simple blood test. If this is the case, then they should utilise the adjacent facilities at the Emergency Department of the hospital.