Boy did not get antibiotics soon enough - inquest

The mother of a three-year-old boy who developed a strep A infection and later died said he was not given antibiotics soon enough before he developed sepsis, an inquest heard.

A jury at Chesterfield Coroner's Court heard Oscar Neillings was seen by two out-of-hours GPs in the days before he was admitted to hospital.

Oscar was transferred to Chesterfield Royal Hospital in an ambulance after another visit to a GP surgery but suffered a cardiac arrest in the evening of 8 November 2023 and died.

Oscar's mother Stephanie Neillings told the inquest: "[For medical professionals] not to recognise sepsis when I had it on my mind... but I thought I was being crazy."

Assistant coroner for Derby and Derbyshire Julie Mitchell instructed the jury to look into whether there were "missed opportunities to treat or escalate his care" and if "failures had any material bearing" in his death.

Oscar, who was described in court by his mother as an "early riser who would love to sing", said he had many friends and had "a confidence I wish I had".

"Oscar was so full of life and that's why it is hard to believe that he's gone," she said.

"The house is very quiet now, what I would give to hear his screams around the house."

The inquest heard Oscar had a chronic cough which would "fluctuate in severity" but it did not impact his day-to-day life and did not cause him breathing difficulty.

He was seen by a paediatric consultant at Chesterfield Royal Hospital to be put on a two-month trial to use a steroid inhaler on 17 October 2023.

The jury was then told Oscar developed a "minor cold" by the end of the month which did not seem to improve and became "tearful and whimpering".

Mrs Neillings said: "You know when your own child isn't themselves… he wasn't even paying attention to his iPad – he didn't have the energy... he just wasn't right."

She told the court Oscar was complaining of a sore throat and after a look at his tonsils, she said she saw a "white pustule" on his tonsils and requested another out-of-hours appointment with a GP.

He was seen by an out-of-hours GP at Ashgate Manor in Chesterfield on 5 November who told his parents Oscar had a "viral upper respiratory infection" and "did not consider he would deteriorate" as well as "no need for hospital escalation", Mrs Mitchell said.

The jury heard Oscar then began to complain of stomach pain and began vomiting. He also had "funny breathing" which the parents had not heard before.

After calling 111, Oscar was seen again at Ashgate Manor out-of-hours service.

Mrs Neillings said: "He was checked over by the doctor, I didn't think too much of it – it reassured us that he was going to be fine and that it was just a virus."

The jury was told strep A infection was not considered.

But the court heard Oscar continued to feel unwell and was unsettled in the night getting out of bed and kept sitting on the landing.

He was seen by GP the next morning where he was examined and had a nebuliser put on him. Mrs Neillings told the inquest Oscar said "help me" to the healthcare staff.

The boy was then sent to Chesterfield Royal Hospital in an ambulance on the morning of 8 November.

Oscar was seen by clinicians who found he had low oxygen levels and a poor respiratory rate. He had a chest X-ray which showed "significant right-sided consolidation" and was given intravenous fluid and steroids.

Mrs Neillings told the court doctors spoke about a chest infection and they were going to administer antibiotics.

Asked about Oscar's care in hospital, Mrs Neillings said: "It was so unorganised – I didn't know what was going on.

"There was a lack of communication between medical staff and us because I had absolutely no idea how poorly he was until right at the end."

Mrs Neillings said a matron came to check on Oscar later in the day and said he had deteriorated and paged for a doctor.

Oscar went into cardiac arrest and died just before 17:30 GMT.

The coroner told the jury Oscar died from 1A sepsis following bronchopneumonia and invasive strep A infection.

Mrs Neillings was asked by the coroner about her general concerns she had at Oscar's care from the out-of-hours appointments and in the hospital.

She said: "I am adamant I saw white pustules on his tonsils but she didn't – at that time if he had the antibiotics then potentially it wouldn't have ended up [in this situation] they would've been the same as they get for strep A.

"It's madness how he was sent home with a viral infection... it doesn't say what the doctor thought it could be... I find it really crazy we were sent away with a viral infection and to keep on the Calpol which wasn't working."

On his care in hospital, she added: "There was a lack of leadership, no-one took control throughout the day... the fact he didn't get the antibiotics when he needed them and they missed their timescales for that.

"We saw so many doctors that day and no one recognised sepsis.

"[For medical professionals] not to recognise sepsis when I had sepsis on my mind... but I thought I was being crazy."

The inquest, which is expected to last three weeks, continues.

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