A hospital trust failed to provide basic medical care to an infant who died from meningitis, a coroner has ruled.
Kingsley Olasupo, who was born alongside his twin sister Princess, was just ten-days-old when he died at the Royal Bolton Hospital on April 18, 2019, after being diagnosed with bacterial meningitis and sepsis. An inquest into the tot's death has heard evidence about "individual and systemic failures" to provide basic medical care to the infant, who would have survived if antibiotics had been administered sooner.
The hearing at Bolton Coroner's Court lasted for four days, and heard from 23 witnesses including midwives and doctors involved in Kingsley's care, dad Tunde Olasupo, and medical experts. Area coroner Peter Sigee gave his findings of fact to the court this afternoon, April 28, after four difficult days of evidence, which often saw members of Kingsley's family break down in tears hearing about the chances to save the beloved baby.
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Today, Mr Sigee outlined his findings from the course of the inquest, which have now been accepted as the factual version of events on the balance of probabilities. He found that Kingsley was likely born with an infection, which is what caused him to struggle to regulate his temperature and be slow to feed right from the start of the tot's life.
Kingsley's low birth weight of 2,020g - below the 10th percentile for his age - the presence of meconium, baby's first poo, during his delivery, and his prematurity of 35 weeks and four days were all risk factors for infection, and should have prompted practitioners to consider his subtle signs of infection as something more sinister - instead of putting them down to prematurity.
However, there were several missed opportunities to effectively escalate concerns about Kingsley, or to identify any clinical indicators showing he was suffering from an infection, so it wasn't until his fourth day of life when the infant was first examined by a doctor, and it took doctors more than 24 hours to identify signs of an infection and start antibiotics.
On April 12, four days into Kingsley's life, he was diagnosed with meningitis and was started on antibiotics to treat the infection. By April 13, blood cultures had identified the bacteria behind the infection as Enterobacter cloacae, and Kingsley was started on appropriate antibiotics to combat this bacteria.
Sadly, Mr Sigee concluded that by this point the infection was "too advanced, and it was too late to successfully treat Kingsley". Tragically, Kingsley's condition continued to deteriorate, until his devastated parents Tunde Olasupo and Nicola Daley were told the best option would be to remove their son's life support. Kingsley died at just ten-days-old.
Bolton NHS Foundation Trust, the British Association of Perinatal Medicine, the National Institute for Health and Care Excellence, and other partners worked together to create and distribute new guidance to medics about the risk of neonatal infection after Kingsley's death, as well as introducing new procedures at the Royal Bolton Hospital in order to ensure the "individual and systemic failures" were not repeated.
Mr Sigee concluded that Kingsley had died as a result of natural causes contributed to by neglect. He said: "In accordance with guidelines, Kingsley should have been assessed by a paediatric doctor within two hours of his birth and every day thereafter, and detailed observations should have been recorded for him.
"If a doctor had seen and assessed Kingsley at any time from birth in accordance with the guidelines then Kingsley would have been screened for infection, first line antibiotics commenced and, within approximately 24 hours of screening, Entrobacter cloacae would have been identified as the infective organism enabling full dosage of mereopeneum to be administered.
"If meropenem had been administered to Kingsley by the early hours of April 12 then he would have survived. There were individual and systemic failures in the post-natal care of Kingsley which meant that Kingsley was not assessed and treated for infection in accordance with applicable guidelines.
"Taken both individually and together, these amounted to a gross failure to provide basic medical care to Kingsley and they were causative of his death."
Mr Sigee commended Kingsley's family for the way they had conducted themselves during the hearing, passing on his condolences and saying they had "waited long enough" for his conclusion - after the initial inquest was delayed from December 2019 when the Trust released their report into the incident just a week before the inquest was due to begin. This hearing was then later delayed even further by the coronavirus pandemic.
Kingsley's family now have seven days to raise any concerns about Kingsley's care that they wish Bolton Hospital Trust to address, where any concerns that have not already been acted upon by the hospital will be submitted to the coroner in order for him to determine whether a Section 28 report, intended to prevent future deaths, is necessary.
The Trust previously admitted liability for Kingsley's death in a civil medical negligence case, writing a full letter of apology to Kingsley's parents and paying them an undisclosed sum of compensation.
Speaking after the inquest, Kingsley's father Tunde Olasupo said: “We want Kingsley to be recognised and remembered as the baby who put new and better policies in place. We want the details of Kingsley’s case to be used in hospitals nationwide to prevent this from happening again.
"No amount of money in the world can ever replace Kingsley; our only wish is that no one else goes through what we have and are failed the way Kingsley was. We will not stop pushing for changes and one of the things we want to push for is a permanent memorial of Kingsley, to always remind the doctors and midwives that simple mistakes can lead to a catastrophic outcome.”
Francis Andrews, medical director at Bolton NHS Foundation Trust said: “On behalf of the Trust, I would like to offer my sincere condolences to Nicola and Tunde for the tragic loss of their little boy, Kingsley. We fully accept the outcome of the inquest and are truly sorry that our care fell below the standards that Kingsley, Nicola and Tunde deserved.
“We undertook a thorough and transparent investigation, and have reviewed our practices and made significant changes. Nothing can take away Nicola and Tunde’s profound grief. "We will continue to do all we can to prevent such a tragedy happening again.”
