A doctor admits making an “error of judgement” in the care of a three-month-old baby with suspected sepsis, an inquest has heard.
Lewys Ryan Aidan Crawford, from Cardiff, died the day after being admitted to A&E at the University Hospital of Wales, with a high temperature.
The infant was initially treated for a lower risk infection but it was eventually established that he had meningococcal septicaemia and sepsis.
An inquest at Pontypridd Coroner’s Court on Tuesday heard Lewys was admitted to the Cardiff A&E at about 8.15pm on March 21, 2019, but medical staff did not administer any precautionary antibiotics until about 3am the following morning.
Giving evidence, paediatric registrar Dr Ifeoma Ujomu told the jury she began her shift at UHW at about 8.30pm and was taking part in a handover meeting when she became aware of Lewys.
Dr Ujomu said she saw two patients before she saw Lewys but was reassured because he had already been seen by a senior consultant.
She told the jury she saw Lewys in A&E at about 10.30pm. Dr Ujomu said she identified he had a fever and suspected a bacterial infection but ordered a full sepsis screening.
She said antibiotics were not administered until about 3am the following morning.
Coroner Graeme Hughes referred Dr Ujomu to a document which contained NICE guidelines for correct management of suspected sepsis cases. Dr Ujomu accepted she was familiar with the document.
Asked what the guidance would have informed her to do, she said: “It would have informed me with hindsight to give the antibiotics down at A&E.”
Mr Hughes asked the witness: “Would that have indicated after you had seen Lewys at around 10.30pm he was a high risk or moderate to high risk of sepsis?”
“High risk,” she said.
She added that antibiotics should have been administered by “any possible route” which in Lewys’s case would have been an “intra-muscular route”.
Dr Ujomu said the guidelines indicated the antibiotics should have been administered within an hour of her consultation with Lewys at about 10.30pm.
She said: “With hindsight it was an error of judgement on my part.”
Staff nurse Lisa Davies told the court she was managing the ward where Lewys was transferred at about 11.30pm that night.
Ms Davies said she was “not happy” about the patient being transferred to her ward until he was stable and a full sepsis screening had been carried out.
She said she saw Lewys on the ward shortly after his arrival where he was sat on his mum’s lap with a bottle.
She saw him again at about 12.45pm by which time staff had inserted a cannula but his condition had worsened.
Ms Davies told the court she was aware Lewys had not received any antibiotics by that time.
Graeme Hughes asked Ms Davies: “From what you know of that protocol ought Lewys to have had antibiotics by that time?”
“He should have yes,” she said.
Why we have inquests:
Ms Davies said Lewys was transferred to an intensive care unit after 3am when his condition did not improve.
She said the infant was “gasping”, “grey” and was displaying an “increased work of breathing”.
Asked if there had been any changes to working practices since Lewys’ death, Ms Davies said: “The first few months there were less admissions to the ward without ticking all the boxes but recently it’s not been done again.
“I think we as nurses, since Lewys as well, we are adamant to say no.”
Lewys Crawford died on March 22, 2019.
The inquest continues.
