An Inquest opens on Tuesday 21 June into the death of an eight-week-old baby who died after being admitted to Bristol Children's Hospital in April 2015.
Ben Condon was born on 17 February 2015 at 29 weeks and was discharged home shortly after.
On 9 April, Ben developed a cough and a few sneezes but his parents, Allyn and Jenny, were advised by a neonatal community nurse that this was normal. Later that evening, concerned about Ben's condition, the family called NHS 111 and were told by the operative that she would arrange an immediate call back from a doctor. That call never came.
Ben started to get worse, so the family drove him to Weston General Hospital. Ben was in a state of hyperthermia and his heart rate was low, and he was subsequently transferred to Bristol Children's Hospital, where he was stabilised while tests were carried out. He was diagnosed with human Metapneumovirus (hMPV), a common cold.
Over the course of the next few days, Ben's condition deteriorated, and it has become apparent that hospital staff suspected he had contracted a secondary infection. Despite discussion of antibiotic administration should his condition deteriorate, and the family's repeated requests for treatment to commence, no such administration took place until half an hour before his death.
Benjamin's condition deteriorated further until he sadly died at 9pm on Friday 17 April. No post mortem was carried out, and Ben's parents later discovered that he had developed a secondary infection, pseudomonas sepsis, that was not addressed in the final days and hours of his life.
Ben's family is convinced that, had diagnosis and treatment of the infection taken place sooner, he would still be with them.
Allegations of misleading information
Following Ben's death, his parents met with senior staff at the Trust several times and were initially told that their son had died from complications including hMPV, acute respiratory distress syndrome (ARDS) and prematurity. However, it was only in a meeting several months after his death that they were told about the secondary infection for the first time.
In a Child Death Review feedback meeting that took place on 22 July 2015, both the parents and Trust staff agreed to audio record the discussion. During a recess, the parents left the room. Whilst they were absent, staff continued to discuss Ben's clinical care, with Consultants suggesting that the family's concerns were serious and acknowledging that errors may have been made. One clinician realised that both of the audio devices were still recording, and suggested that the recess discussion should be deleted because the section could 'get them into trouble'.
Following this, the family became hugely concerned that potential failures in Ben's care were being covered up by Trust management. An independent report was eventually commissioned by the Trust, which found that there had been a number of serious failings in communication with the family, including two Consultants giving misleading information about blood tests having been taken. The Trust has apologised 'unreservedly' to the family and has published the report, produced by Verita, on its website.
During their campaign for answers, the family has met with Health Secretary Jeremy Hunt to discuss the safety of care at Bristol and how the lessons of Ben's death can be applied on a wider scale.
A Coroner's Inquest is guided by strict basic principles: to establish who died, and where, when and how he died. It is not within the scope of a Coroner's investigation to make findings of blame with regard to any particular individual, although the coroner can write to institutions such as NHS trusts with recommendations for changes in practice if it is felt that patient safety is at risk.
While there has been a great deal of investigation that has taken place after Ben's death, both by the hospital and the parents themselves, the Coroner will come to a conclusion on the evidence she feels is appropriate within the remit of her inquiry.
Laurence Vick, the family's solicitor, says:
'This has been a very long and difficult road for Allyn and Jenny. With every passing month, more information has emerged about their son's treatment and this has only added to their frustration and anxiety. They are not setting out to demonize the Trust but, in many instances, one has to agree that there has been a lack of candour which they understandably find hugely upsetting.
'The Coroner may not be prepared to address the issues of misleading information being given to parents during the death review process – taking the view that this is not part of her role. We trust, however, that she will carry out a searching investigation of the circumstances of Ben's death, hopefully giving the family some of the answers they seek.'
The Inquest will be held at Avon coroner's office and is scheduled to last for two days.