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NHS bosses are set to conduct a full review of child care at Darent Valley Hospital following the death of a six-year-old boy.
Leon Singh, from Erith , was admitted to the hospital in Dartford on May 1, 2019, with a series of symptoms including a high temperature and a rash on his body.
An inquest looking into the full circumstances leading up to his death concluded at Maidstone County Hall today, and Dartford and Gravesham NHS Trust has apologised that its care fell below standard.
Following the four-day inquest, the assistant coroner ruled that there were "missed opportunities" to diagnose the septic shock and for effective clinical management and treatment.
The findings have prompted Leon’s family, who have instructed law firm Simpson Millar as part of their efforts to better understand the circumstances surrounding his death, to plead for reassurances that lessons learnt have been acted upon to prevent further tragedies.
During the inquest, evidence was also heard of a series of other issues - including a failure to complete sepsis charts which would have helped identify the presence of potential symptoms, and poor communication between clinicians.
Earlier in the week, assistant coroner Alan Blunsdon said: "At the time of death he resided in Erith. I understand that on April 21 Leon became unwell.
"On May 3, 2019, his condition deteriorated. At this time, he was a patient at Darent Valley Hospital.
"A decision was taken to transfer him to Evelina London Children's Hospital on May 3, but sadly he died the next day."
Concluding a narrative verdict today, Mr Blunsdon said: "By the early morning of May 2, 2019 he [Leon] probably had compensated septic shock and later that morning decompensated septic shock with falling blood pressure.
"It is probable that the toxic shock resulted from the administration of cytolytic antibiotics and release of toxins.
"There were missed opportunities to diagnose the septic shock in sufficient time for effective clinical
management and appropriate treatment."
It was revealed the primary school age pupil had suffered from a rare condition known as Kawasaki disease six months prior to his death.
Symptoms included a rash, swollen glands in the neck, dry, cracked lips and red eyes.
When a rash and persistent high temperature returned in April last year, Leon was taken to his GP in Northumberland Heath, who made an initial diagnosis of tonsillitis and prescribed a course of antibiotics, the inquest heard.
His condition did not improve and his mum pushed for a referral to Darent Valley Hospital.
A statement was read to the court on behalf of his mum, Samantha Singh.
It read: "Leon seemed perfectly fine, playing with superhero toys and was doing push ups on the bed saying he wanted an ice lolly.
"We were told he was improving and then in a couple of hours he was gone. We don't understand how this could have happened."
Following the inquest, medical law expert Rebecca Brunton from Simpson Millar, spoke on behalf of Leon's family.
She said: “The family have been devastated by the loss of Leon.
“While they thank the Coroner for his time, the inquest has understandably been a very difficult time for them, especially with so much evidence to suggest that there were missed opportunities to diagnose him and provide swift, effective treatment.
“They are now desperate for reassurances that lessons learnt have been acted upon by the Trust, to ensure no one suffers as they have in the future.”
Leon’s mother Samantha said: “Nothing will ever replace what we lost when Leon died.
“He was the glue that brought our family together, and to hear throughout the inquest that there were missed opportunities to recognise and treat his sepsis is beyond heartbreaking.
“It is unimaginable that this pain will ever go away.”
A statement from Dartford and Gravesham NHS Trust said: “We offer our sincere condolences and sympathies to the family for the tragic loss of their son Leon and the suffering that this has caused. We have shared all of our findings with the family and have apologised to them that Leon’s care fell below the standard that they were entitled to expect.
We have now put a full range of actions in place. We have embarked upon a full review of paediatric care at Darent Valley Hospital, commissioned an invited College review and established a Children’s Board. We have already started sharing the findings of the review and the resulting actions with the Care Quality Commission (CQC).”
