A three-year-old boy died in hospital hours after a GP missed “red and amber flags of sepsis” and told his mother his symptoms would get better on their own.
Isaac Onyeka, from Loughton in north-east London, died on May 31 last year after contracting a Strep A infection, which led to the condition.
A coroner has now raised concerns in a Prevention of Future Deaths report over contact his mother had with both a GP and the NHS 111 telephone service, as she sought medical help in the days before his death.
Isaac began showing signs of chickenpox on May 26. On the evening of May 30, his mother found a painful swelling under his arm, and rang NHS 111 for advice.
A health adviser said Isaac should be assessed by his GP within 24 hours.
When the GP registrar at the Forest Practice in Loughton carried out the telephone consultation the next morning they failed to pick up on warning signs of sepsis.
“In assessing Isaac’s risk of a serious infection, the GP registrar did not consider two applicable risk factors, namely the immune deficiency associated with Down’s Syndrome and the raised risk of Group A streptococcal infection associated with chickenpox”, coroner Nadia Persaud said in a Prevention of Future Deaths report.
She said Isaac should have been sent to hospital following the consultation, but instead his mother was advised his lumps - thought to be swollen lymph nodes - “would likely self-resolve”.
At home that afternoon, Isaac became unresponsive. His mother tried to resuscitate him, as did paramedics who arrived by both road and air ambulance.
Isaac was taken to Whipps Cross Hospital in east London, where he died later the same day.
Ms Pernaud said it was “unlikely” his death would have been avoided even if he had been taken to hospital that morning, as the onset of the sepsis was so severe.
But she said the death “would have been avoided” had the NHS 111 call handler who took the mother’s earlier call known Isaac had Down’s Syndrome, as it meant he would have been assessed by a doctor that evening.
Ms Persaud raised concerns over the fact health advisers with NHS 111 do not have access to patients’ GP electronic summaries - that would have included the fact Isaac had Down’s Syndrome.
She suggested NHS call handlers would be better equipped if they had details of patients’ past diagnoses, writing: “Application of the current NHS 111 Pathways assessment did not capture all of the necessary background clinical detail, which could have resulted in the necessary hospital disposition on May 30.”
Ms Persaud also raised concerns over a “knowledge gap” among medics, parents of children with Down’s Syndrome, and the public, over the immune deficiency associated with the syndrome, that places them at higher risk from sepsis.
During Isaac’s inquest, an independent paediatric expert said: “[Down’s] Syndrome is the most common genetic disorder associated with immune defects. Children with [Down’s] Syndrome need to be managed with a heightened sense of awareness in the setting of sepsis.”
“This was not however known by Isaac’s parents or by the GP registrar,” said Ms Persaud in her report.
She also raised concerns over a lack of central resource for helping parents recognise signs of sepsis in children with darker skin colours.
A Forest Practice spokesperson said: “We continue to closely support Isaac’s family following this extremely sad event and we feel their loss immensely.
“The practice has thoroughly investigated this event to identify any learning that will strengthen our patient care, including providing training for all practice staff and reviewing our appointments.
“We have worked with our local integrated care board so that this learning can be shared more widely, and we also await NHS England’s response to the Coroner’s Prevention of Future Deaths report.”
An NHS spokesperson said: “NHS England extends its deepest sympathies to the family and friends of Isaac Onyeka. We are carefully considering the Prevention of Future Deaths Report sent to us by the coroner and will respond in due course.
“It is vital that we do all we can to ensure the signs of sepsis are spotted in all patients – the NHS has worked with the Royal College of Paediatrics and Child health and the UK Sepsis Trust to update the questions call handlers ask so they can better spot the signs of sepsis and advise people to attend an emergency department within one hour.”
Isaac’s death follows a number of other tragic incidents in recent years, in which children have died after their sepsis was not diagnosed in time, or symptoms were missed.
London NHS bosses called for an urgent review of sepsis care at Kingston hospital after 11-month-old baby Martyn Mirchev died last May following delays in his treatment.
In November, the Standard reported how Daniel Klosi, four, from Camden, died of sepsis just hours after being sent home from the Royal Free Hospital, where his parents were reportedly told to give him Calpol.
In 2021, 13-year-old Martha Mills died at King’s College Hospital after developing sepsis following a bike accident on a family holiday in Wales.
An inquest later heard that she would have survived had consultants at the hospital moved her to intensive care sooner.
Following her death, Martha’s parents have campaigned for the creation of Martha’s Rule - which is being introduced by the NHS this month - to give families the right to a second medical opinion when a loved one’s condition is deteriorating.
Sepsis is a life-threatening condition that can be hard to spot, especially in children.
There are a broad range of possible symptoms that resemble other conditions, including flu or a chest infection.
Call 999 or go to A&E if a baby or young child as any of these symptoms of sepsis:
- blue, grey, pale, or blotchy skin, lips, or tongue – on brown or black skin, this may be easier to see on the palms of the hands or soles of the feet
- a rash that does not fade when you roll a glass over it, the same as meningitis
- difficulty breathing (you may notice grunting noises or their stomach sucking under their ribcage), breathlessness, or breathing very fast
- a weak, high-pitched cry that’s not like their normal cry
- not responding like they normally do, or not interested in feeding or normal activities
- being sleepier than normal or difficult to wake
For more information on symptoms, visit the NHS website.
