DOCTORS missed three opportunities to save a baby’s life by failing to give him antibiotics, a coroner said yesterday.
Lewis Mullins, who had just turned one, was suffering from chicken pox and died after he was sent home three times by medics in the space of three days, an inquest heard.
Rotherham coroner Nicola Mundy said: “Had appropriate treatment been given on each of those three occasions it is likely Lewis would have survived.”
Delivering a narrative verdict she said: “A number of nurses and doctors were involved in Lewis’s care over a short period of time but nobody looked at the entire picture. Ultimately this led to Lewis’s death.”
The child’s parents Jodie Conlay, 28, and Andrew Mullins, 32, wept openly as the coroner delivered her verdict.
Lewis was examined by a GP at an NHS walk-in centre and then twice by hospital doctors within the space of three days.
None of the doctors gave Lewis blood tests or an X-ray which would have shown an infection.
His worried parents repeatedly told doctors their son was seriously ill, but they were only given an anti-viral drug and painkillers.
Lewis died from pneumonia which was likely to have been caused by the chicken pox.
Ms Mundy said that Lewis was showing signs of a secondary bacterial infection but those symptoms “were not properly heeded and acted upon.”
The missed opportunities led to the infection progressing and then his death, on April 2 last year.
Dr Kate Ward, an expert in child protection who reviewed Lewis’ case, said he would probably have survived had he been given antibiotics on the three occasions he was sent home.
She added that doctors concentrated too much on the chicken pox without looking for a secondary bacterial infection.
Lewis’s mother took him to Rotherham’s NHS walk-in centre on March 30 last year but a questionnaire filled in by a triage nurse detailing Lewis’s symptoms was not passed to GP Dr Ali Kouchouk, who merely thought he was treating him for chicken pox.
The doctor admitted it was “fairly significant information” and, had he known, it may have been more appropriate to send Lewis to hospital.
Lewis developed a new rash and was admitted to the A&E department at Rotherham District Hospital the next day.
There, senior house officer Dr Dhanitha Srivatsa pronounced Lewis a “very happy smiling child” and he was discharged with ibuprofen and paracetamol.
But Miss Conlay and Mr Mullins thought Lewis had worsened and he was re-admitted to the hospital on April 1.
Junior doctor Teresa Hamilton found Lewis “generally well”, discussed the case with a senior house officer and Lewis was discharged for a second time with painkillers. Within 24 hours the baby was found lifeless at home.
The coroner said she would be writing to the Lord Chancellor and the walk-in centre over their systems and the failure to pass his medical questionnaire to the GP.
Ms Mundy said Lewis developed pneumonia due to chicken pox.
She added: “In my view he was displaying sufficient symptoms to warrant further investigation.”
Pathologist Dr Al-Adnani said Lewis said the chicken pox made Lewis more vulnerable and probably caused the pneumonia.
Following Lewis’s death, Rotherham Hospital implemented big changes. All children with chicken pox are now given antibiotics and are physically examined within four hours of admission.
Ms Mundy said she would be writing to the Department of Health to highlight Lewis’s cas.
Later Miss Conlay said: “Hearing that the treatment given to Lewis could have been different and could have saved his life was completely soul destroying. I just hope now that changes can be made, and more notice taken of parents’ concerns, to try and prevent others from having to go through the heartache that we have.”