Leytonstone News

Three-year-old boy would have survived sepsis with quicker hospital referral, coroner rules

Isaac Onyeka died at Whipps Cross Hospital on 31st May last year following a Strep A infection that led to sepsis, reports Marco Marcelline

Main image: Whipps Cross Hospital

The death of a three-year-old boy with down’s syndrome could have been avoided if he had been referred to hospital a day earlier, a coroner has ruled.

Isaac Onyeka, from Loughton, Essex, died while receiving emergency treatment for sepsis at Whipps Cross Hospital on 31st May last year.

In the days leading up to his death, Isaac had been suffering from chicken pox. On the evening of 30th May, Isaac’s mother noticed that he had a painful swelling under his arm, and called NHS 111. The health advisor, who was not told or aware that he had Down’s, organised for Isaac to be assessed by his GP the next morning. 

That morning, she was asked to provide photographs of the swelling Isaac was suffering from to her GP practice which was then viewed by her GP. Isaac’s mother also provided “important clinical detail” but this was not seen by the GP. 

In a Prevention of Future Deaths report, Nadia Persaud, the area coroner for East London, said that Isaac died after “red and amber flags” of sepsis were missed by the GP when assessing him.

She wrote: “In assessing Isaac’s risk of serious infection, the GP did not consider two risk factors, namely immune deficiency associated with Down’s syndrome and the raised risk of Group A streptococcal infection associated with chickenpox.”

Isaac, the coroner said, should have been directed to hospital after the consultation but his mother was instead advised that the lymphadenopathy he was suffering from would likely “self-resolve”. 

Hours after the phone call, Isaac became unresponsive at home and was rushed to Whipps Cross Hospital.

In her prevention of future deaths report, Ms. Persaud said that a further hurdle that stymied the response to Isaac was that NHS 111 health advisors do not have access to GP electronic summaries.


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If the advisor handling Isacc’s mother’s call on 30th May had this access, they would have known that he was diagnosed with Down’s and he would have in turn been assessed by a clinician that evening instead of the following morning, Ms. Persaud wrote.

The coroner also raised concerns about a “knowledge gap” in the public, and specifically among parents of children with Down’s, in regards to the immune deficiency associated with the genetic condition. 

This deficiency means that children with Down’s need to be managed with a “heightened sense of awareness in the setting of sepsis”. This was not possible in the case of Isaac because the deficiency was not known by his parents or the GP.

Writing to the national medical director of NHS England, Ms.Persaud also expressed concern about there being no central resource that helps families to recognise signs of sepsis in patients with darker skins. 

At a pre-inquest hearing into Isaac’s death in October last year, a court heard how the young boy had been frequently seen by hospitals for various conditions; in November 2019 he was treated for bronchiolitis, and in July 2021 he was seen for an upper respiratory tract infection, while in May 2022, he attended hospital with a cough and fever.

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.”

For more information on sepsis symptoms, visit the NHS website.


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