New measures for accessing medical records have been put in place after a four-year-old boy died when he inhaled his own vomit while lying in a hospital bed.
During a two-day inquest it became clear that medical staff dealing with Daniel Hames during his stay in Doncaster Royal Infirmary did not have access to his full medical history.
The youngster was also not assessed at regular intervals during his six-and-a-half hours in the hospital. One nurse even went on a two-hour break when she was due to monitor Daniel’s condition, Doncaster Coroner’s Court was told.
Assistant coroner John Sleightholme told Daniel’s family that ‘communications in some way could have done better’. However, he also ruled that his death was due to natural causes.
Hospital bosses sacked a member of staff following Daniel’s death.
Daniel, known as Dan Dan, was suffering acute gastroenteritis when he died on March 3 last year.
The court heard he had been vomiting the day before, and had already been seen at hospital that afternoon.
The doctor advised his family to take him home, making sure he drank liquids after he stopped being sick.
But hours later Daniel was rushed back to the DRI by ambulance and admitted to A&E.
The inquest heard he had been ill several times with the same condition the year before - leading to him being hospitalised for four days in June 2012 - and had been sent home from school suffering diarrhoea in February 2013.
The inquest was told that, since Daniel’s death, a Serious Incident report was made.
Following that, a pilot scheme making medical records more easily available between 11pm and 7am has been put in place by Doncaster and Bassetlaw Hospitals NHS Foundation Trust. And a new system called the Paediatric Advanced Warning System has been introduced, specifically to monitor observation results of children and flag up any that would cause concern.
The inquest heard that Daniel was admitted to a paediatric ward. A staff nurse who was told about Daniel’s condition then told a colleague to carry out observations - which she did not do - while she took a two-hour break.
When Mr Sleightholme asked the hospital matron about the length of the break and if that was normal, she replied: “The length of time was not acceptable nor, I am aware, common practice.”
The cause of death was given as acute aspiration of stomach contents due to adenoviral gastroenteritis.
Speaking after the inquest Daniel’s dad, also called Daniel, 29, said: “He was a well loved and happy child and he is going to be missed by his mum, dad, granny and grandad.”
Mike Pinkerton, chief executive of Doncaster and Bassetlaw Hospitals, said: “While nothing we can say can reverse the events of March 3, 2013, we would again extend our sincerest sympathies to Daniel’s family, and our apology for aspects of his care that were below the standard we expect.
“We hope the conclusion of the inquest brings his family some degree of closure.”