Child's death was avoidable as hospital wrongly discharged him

What happened

S had complex health needs, including developmental delay, epilepsy and cerebral palsy and had previously suffered from repeated lower respiratory tract infections. In late 2013 his mother was concerned that he was unwell with a high temperature, and called an ambulance. The ambulance took S to the Trust's A&E department at about 9pm. Once there, a consultant in emergency medicine's initial assessment said that S might have sepsis. Doctors gave S paracetamol to control his temperature and monitored him. Between then and midnight, a paediatric registrar gave S intravenous antibiotics.

In the early hours of the following day a second paediatric registrar discharged S. He died at home later that morning from sepsis.

What we found

We upheld this complaint. We found that S's death could have been avoided. There were different accounts of what happened, in particular in relation to the decision to discharge S. We concluded that it was likely to have been at the time S's mother told us it was, and that medical records made at the time were not consistent with the second registrar's explanation for the decision to discharge.

The Trust's initial treatment was appropriate but there was insufficient evidence to support the second registrar's account of the timing of, and reasons for the discharge. It was not reasonable to discharge S so soon, given that there was no evidence of significant improvement, and that had he stayed in hospital it was more likely that he would have survived. The second registrar did not comply with the professional standard that entries in medical records should be made as soon as possible after the event, and if there is a delay, the time of the event and the delay should be recorded.

Putting it right

The Trust provided S's parents with an open and honest acknowledgement of the failings we identified, an apology and a payment of £15,000 in recognition of the fact that S's death was avoidable and that they will have to live with knowing that to be so. The Trust also prepared an action plan describing what it had done to make sure that the organisation and the second registrar had learnt lessons from the failings, so that a similar situation would not happen again. We sent the report to the General Medical Council in connection with the second Registrar's handling, and asked it to consider whether his fitness to practise had been impaired.