Baby died after 'missed opportunity' to give 'potentially life-saving' sepsis treatment
A three-month-old baby who died of sepsis missed out on "potentially life-saving" treatment, an inquest has revealed.
Lewys Ryan Aidan Crawford died the day after being taken to A&E at the University Hospital of Wales, after his parents had raised concerns over his temperature.
On Monday, Pontypridd Coroner's Court heard how 13-week-old Lewys had been a "healthy" baby before becoming ill in March last year.
He turned "purple" and ballooned in size in the hospital when meningococcal septicaemia was originally thought to be a viral infection.
Lewys' mother, Kirsty Link, and her partner, Aidan Crawford, took Lewys to the paedatric A&E department after he woke up and "wasn't himself."
Ms Link, from St Mellons, Cardiff, said: "Lewys ballooned in size, he was purple all over. I kept asking the doctor what they were doing, and did they have a diagnosis, to which the response was no.
"Eventually we were given a diagnosis Lewis had meningitis on March 22."
In a statement read to the jury, Ms Link expressed concern about the delay between Lewys admitted to the unit to him receiving his first course of antibiotics.
"I am concerned about the length of time it took to get the diagnosis."
Paediatric emergency unit nurse Rebecca Murphy gave evidence at the inquest.
She said the unit had been "extremely busy" on the night Lewys arrived in hospital, with 16 patients were waiting to be seen by a doctor.
The department was missing an emergency nurse practitioner, a paediatric consultant and any staff on a level six qualification scale.
Miss Murphy had observed Lewys, and he was classed as "unwell" before being transferred to the Noah's Ark Children's Hospital for Wales.
But Miss Murphy became concerned and asked for a doctor to see Lewys after being told there would be a half hour delay to get him a bed, the inquest heard.
Attempts to give Lewys Ibuprofen, and later attempts to fit a cannula, were unsuccessful in the emergency department.
Miss Murphy said she "did not feel he was safe enough to be transferred to the ward."
While the nurse said she suspected Lewys might have contracted sepsis after reviewing sepsis guidelines, she said she did not recall discussing the condition with colleagues.
"I felt Lewys needed a line and antibiotics just from my understanding of sepsis," she said.
In her shift report, Miss Murphy wrote: "Raised my concerns [regarding] elevated heart rate and the need for antibiotics as per sepsis guidelines."
In the inquest, Miss Murphy accepted she should have recorded the word sepsis in her observations.
Emergency medicine consultant Jo Mower also gave evidence. She had been working in the A&E's adult department before going to help with minor injuries in the paediatric emergency unit.
She was called on by Ms Murphy to review Lewys, and after observing him believed him to have a viral infection.
It was not until Lewys was transferred to a bed that he was eventually diagnosed with meningococcal septicaemia.
Dr Mower said: "You see a lot of children with temperatures which turns out not to be meningococcal septicaemia.
"It's quite rare to see someone as young as three months and the children I have seen [with meningococcal septicaemia] have been older."
When asked if she had considered Lewys to have sepsis, Dr Mower said: "No. At the time I was thinking he was a hot child.
"In hindsight I didn't think of sepsis at that time, at that point."
The coroner told the court he had instructed an independent expert to look into the circumstances surrounding Lewys's death.
The emergency consultant agreed that Dr Mower's observation was the "first missed opportunity for prompt and potentially life-saving treatment in the case of sepsis."
The inquest continues.