Following a five-day jury inquest conducted by the Greater Suffolk Coroner Mr Nigel Parsley, which closed on 07 June, the jury concluded that six-year old Oliver Hall’s death on 24 October 2017 was from natural causes contributed to by neglect due to a gross failure to provide basic medical treatment.
The Corner also raised concerns that the current 999 system gave rise to a risk of future deaths in relation to the accuracy of information passed between the 111 and 999 services as well as between 999 and GPs in life threatening situations.
Oliver died at James Paget University Hospital less than a day after contracting the bacterial infection Meningitis B. His mother, Georgie, called the GP practice before 10 am asking for an urgent appointment but was told none were available until late afternoon. As Ollie was getting worse, Georgie called the GP surgery again to ask if he could be seen earlier. Whilst waiting for a return call, she decided to call 111 who concluded that Oliver was suffering from a life-threatening illness and an emergency ambulance was sent.
Georgie told the paramedics of her concerns, however despite the fact that Oliver had displayed classic symptoms of meningitis, the ambulance crew insisted that he did not need to go to hospital. Instead, Oliver was taken to his GP practice where he was seen by two different GPs, neither of whom thought there was cause for concern because “they failed to adequately undertake basic medical assessments”. Tragically, Oliver and his mother were sent home.
His condition deteriorated still further and Georgie took her son back to the GP practice later that evening. Oliver was immediately given antibiotics and an emergency ambulance was called. The ambulance did not arrive due to high demand. The ambulance service, however, failed to advise the GP of the lack of available resources, causing further delay. Eventually, Georgie and her husband Bryan drove Oliver straight to hospital themselves, arriving at James Paget’s at around 8 pm. Tragically, despite the best efforts of the medical staff at the hospital, Oliver passed away in the early hours of 24 October 2017.
The Inquest heard from expert witness Dr Niall Cameron, who described meningitis as: “A smouldering fire that could suddenly burst into flames. It has to be treated with extreme caution.”
A second GP expert giving evidence, Dr Sarbani Ray, stated that the GPs failed to undertake basic medical assessments which even the most inexperienced junior doctor should be able to perform.
The inquest also heard from Professor Nigel Klein, a paediatrician and professor of infectious diseases, who concluded that if the ambulance crew or the GPs had given Oliver penicillin and sent him to hospital, he would have survived.
"The neglect verdict reflects what Georgie and Bryan believed all along – that Oliver lost his life because the medical professionals failed to adequately undertake the most basic of medical assessments. The coroner has also identified a number of systemic problems with the 999 system which pose a risk to life across the whole country. It is hoped that, as a result of this inquest, those system problems can be rectified.
While the family welcome the Coroner’s recommendations to improve communication between various health professionals, they still fail to understand why their genuine concerns that Oliver could have meningitis were ignored or dismissed so readily and repeatedly."
"This tragic story highlights the need for health professionals to give greater credence to parental concerns. No one knows their child better than a parent and given the fact Georgie repeatedly raised the possibility of meningitis, it is very troubling that her worries were dismissed without even the simple tests that could have reassured her or confirmed a potentially life-saving diagnosis."
The family will now consult with their legal team to consider what next steps might be open to them following the verdict.