Concerns at Notts hospital after baby's sepsis death

A Prevention of Future Deaths (PFD) report has been issued by a coroner after a ten-week-old baby boy died from sepsis in Kings Mill Hospital, Sutton-in-Ashfield.

Tommy Gillman was admitted to King's Mill Hospital, part of Sherwood Forest Hospitals NHS Foundation Trust, on 7 December 2022 but died the next day.

An inquest heard the seriousness of his infection was not recognised for hours.

Tommy Gillman, from Coddington, Nottinghamshire, was "extremely unwell" with what proved to be salmonella Brandenburg meningitis when admitted to the Sutton-in-Ashfield hospital at 12:35 GMT.

His assessment was delayed, and then the severity of his condition was missed, meaning correct treatment with antibiotics and fluids did not start until 17:00.

During the inquest his parents, Tamzin Myers and Charlie Gillman, said despite informing staff of Tommy's history of infections, they "were not listened to."

East Midlands assistant coroner, Dr Elizabeth Didcock said the system for assessing an ill baby in the emergency department was not "robust" and that action should be taken. She issued a Prevention of Future Deaths report to Sherwood Forest Hospitals NHS Foundation Trust.

The PFD identified a lack of experienced paediatric nurses and confusion in handovers between staff.

The assistant coroner said: "I am not reassured that necessary actions to address these serious issues identified are in place."

However, Dr Didcock said there was no way of knowing whether earlier treatment would have saved Tommy's life.                 

Responding to the PFD, Ms Myers said: "We still have these unanswered questions about whether or not it would have made a difference or not, but he still deserved a fighting chance, and they should have seen him earlier. I'm hoping that these changes will be put in place and no other children have to die."

Tommy Gillman ‘s death came just two days after that of Meha Carneiro, a five-year-old who died after developing sepsis caused by the bacterial infection which was also the subject of a separate highly-critical coroner's report.

Sherwood Forest Hospitals NHS Foundation Trust said it welcomed the review of the baby’s death and a "rapid" programme of improvements was being worked on.

The trust’s medical director, Dr David Selwyn, said: "We would like to express our deepest condolences and reiterate our unreserved apologies to the families of both Meha and Tommy for their losses.

"As a trust, we are committed to providing outstanding care to all our patients and we have welcomed the additional scrutiny that the coroner's review has brought into both cases to identify opportunities where we can learn and improve."