Coroner finds ‘failings’ in care of 19-month-old boy who died of dehydration

Raymond and Lucy Connolly, the parents of Harry Connolly.
Raymond and Lucy Connolly, the parents of Harry Connolly.

THE CORONER for Northamptonshire has identified a series of “failings and catastrophic” mistakes made by medical staff at Northampton General Hospital (NGH) who treated a 19-month-old boy who later died of dehydration.

Harry Connolly died at home in Parkfield Avenue, Delapre, Northampton, on May 1 last year and tests showed he died of dehydration and acute kidney failure after suffering from an inflammation of the colon.

Harry Connolly

Harry Connolly

In the days before he died, Harry suffered from severe diarrhoea and vomiting and was twice admitted to NGH and, two days before he died, was taken to the ‘Northamptonshire Out of Hours’ run by South East Health Limited (SEHL) GP out-of-hours service in the grounds of the hospital.

At an inquest held at the hospital yesterday, county coroner Anne Pember, recording a narrative verdict and catalogued a series of “failures” made by the doctors and nurses who treated Harry.

Mrs Pember said: “Windows of opportunity to treat Harry were lost. These were on the first occasion he was discharged from NGH, the second time when he was only seen for a few hours and when he was seen at out of hours service.

“Had Harry remained in hospital or been readmitted with a robust care plan, his chances of survival would have been enhanced.”

The coroner also described the disorganised arrangements for the ‘open 48-hour access to the ward system’, which should have allowed Mrs Connolly to take her son back into hospital two days before he died, as “catastrophic”.

Mrs Pember said there was a “failure” to weigh Harry the day after he had been admitted to hospital and when he was re-admitted, and described disclosure of advice to Mrs Connolly about how to hydrate Harry at home as “inadequate”.

Mrs Pember also highlighted the fact no blood or urine sample had been taken from Harry “which would have assisted diagnosis of his condition” and said there was a failure to administer satisfactory fluids either through an intravenous drip or through a catheter.

Phil Barnes, of Access Legal from Shoosmiths, representing the family, had asked Mrs Pember to record neglect as part of her verdict but the coroner said she did not feel there had been a “gross failure” to provide basic medical attention.

‘Our son was failed by health system’

THE parents of Harry Connolly said the traumatic experience of watching their son’s health deteriorate in less than a week will “haunt them for the rest of their lives”.

Speaking after the inquest, Lucy and Raymond Connolly said they continue to feel “angry and distressed” about what happened to their son but hope the recommendations that have come out of the inquest will prevent the same thing from happening to another child.

Mrs Connolly said: “We still feel very angry as it is hard to deal with his death as it should not have happened. Children should not die of dehydration and renal failure. As a parent, I have learnt you should always trust your motherly instinct as I was right. I kept telling the medical staff that Harry was extremely sick but nobody would listen.”

In a joint statement, Mr and Mrs Connolly said they “strongly believed” that Harry was failed by the “sub-standard care” given to him by the hospital and Dr Aboo Thamby, the doctor at the out-of-hours service.

They said: “We strongly believe Harry would have recovered and survived if he had remained in hospital on April 26 and been rehydrated, properly assessed, weighed, and given nutritional support. Furthermore, we feel he would have survived if he had been readmitted on April 28.

“The medical providers were given a third opportunity to save Harry on April 29. Instead he was turned away from hospital due to inaccurate open access arrangements, and later by Dr Thamby.”

Lucy Connolly described to theinquest the management of the care of her son as “sub standard” with mistakes and poor treatment from his first admission to Northampton General Hospital (NGH):

APRIL 26: Harry was first referred to NGH by his GP after his parents had become worried that he had been suffering from diarrhoea for four days. On his arrival at NGH, Harry was examined by Dr Farhana Shamim, who assessed he was not dehydrated but recommended that he be given Dioralyte, which helps replace salts and sugars lost from diarrhoea. Harry was initially looked after by a nurse who gave Harry ‘juice’ as he was “not tolerating” Dioralyte. A fluid chart was set up for Harry, however, it was not updated for several hours overnight, and he was not weighed the following morning to see how much weight he may have lost through diarrhoea and vomiting.

APRIL 27: Harry was discharged at about 10.30am after being examined by Dr Ayevbekpen Omorgie who said the parents could have a ‘48-hour open access’ to the ward.

APRIL 28: At about 3.30pm, Harry was readmitted to hospital after his parents felt his condition had deteriorated. Harry was examined by Dr Tasnim Arif who said she did not believe he was dehydrated and recommended that he be given more Dioralyte. Harry was not reweighed and no blood test was carried out. At 5.41pm, Dr Arif then discharged Harry from the ward and his parents were again told they had ‘open access’ to the ward.

APRIL 29: Harry’s condition deteriorated again and his parents described their son’s appearance as ‘lifeless’. Harry’s grandmother, Val Faulkner, rang NGH and was told by a nurse they should take the toddler to their GP or accident and emergency. The nurse could not find Harry’s notes or any paperwork which showed he had ‘48-hour access’ to the ward. This information would have been available if the electronic notes had been checked. After phoning the GP out-of-hours service, the family spoke to Dr Mary McCracken who said they should bring him in to the out-of-hours service as he may be suffering from dehydration. At the out of hours service, Harry was examined by Dr Aboo Thamby who assessed that he was not dehydrated and did not need to be readmitted to NGH. Dr Thamby advised the parents to try to get Harry to eat some rice or yoghurt.

APRIL 30: Harry’s parents reported that he was “brighter” but his fingers and toes were very cold.

MAY 1: At 4am Harry was found dead in his bed by his father.