A five-month-old baby died after doctors at Frimley Park Hospital failed to identify the symptoms of a serious infection, an inquest has heard.
Jackson Chadd, described as a healthy and happy boy, was the youngest of the six children of Farnborough parents Vanessa and Jason.
He fell ill on Monday August 6 in 2012 and, despite spending more than seven hours in A&E at Frimley Park, was not admitted or observed by a senior specialist and was sent home.
Mrs Chadd was told the illness was probably a viral infection manifesting as a cold. However, Jackson was rushed back to hospital hours later and died at 6.05am the next morning.
At an inquest into his death held at Woking Coroner’s Court last Thursday (March 20), assistant coroner Karen Henderson concluded he died from meningococcal septicaemia – a blood infection caused by the meningococcal bacteria that can cause meningitis.
She said doctors "missed [an] opportunity" to treat Jackson.
“I find seven hours without a senior review simply inadequate, and coroners do not use words like that very frequently at all,” she said.
Mrs Chadd, a midwife at Frimley Park, said she knew straight away something was not right with Jackson as he appeared irritable and his hands turned blue.
His "evolving" condition led to him suffering diarrhoea later in the evening, accompanied by a rash.
Mrs Chadd said she felt her concerns had been "dismissed" by hospital staff, and she was made to feel like she was overreacting.
“I said as we were leaving, ‘I’ve got a feeling we’ll be back here tonight’, and we were,” she said.
Jackson had a fast heart rate and high temperature when he arrived at around 4.30pm, which remained until he was discharged at 11.30pm.
The doctors who gave evidence, one of whom only had a week’s experience of caring for children, said they did not believe Jackson’s condition was critical because he was smiling and making eye contact during observations.
Two independent specialists summoned to the hearing said they felt the baby should have been admitted to hospital.
Dr Oli Rahman, a paediatric consultant from Brighton, said there were "two ways of looking at the evolving picture" and Jackson’s consistently high temperature would have rung "alarm bells with some junior doctors but not others".
He said Jackson would have been far more likely to be admitted if a senior doctor had looked at him.
Dr Ian Maconochie, an experienced paediatric A&E consultant in London, said Jackson would have been unlikely to survive even if he had been admitted.
His report for the police concluded that the lack of action by the doctors at Frimley Park did not warrant a criminal investigation.
The snapshot assessments carried out by a series of doctors and nurses were said to have been a factor in them not realising the rate at which Jackson’s condition was developing.
As a result of Jackson’s death, Frimley Park now has a consultant paediatrician working 9am to 5pm on weekdays and a second registrar. The condition of every child under the age of one is now discussed with a registrar.
Mrs Henderson nevertheless decided she would be filing a "prevention of future deaths" report outlining her concerns about the lack of out-of-hours cover at Frimley Park.
She returned a narrative verdict that Jackson died due to his infection not being realised or treated, adding: “I’m satisfied it was a systems failure.”