THE jury at the three-day inquest of Cheshire toddler Olly Stopforth, who died in March 2020, gave a lengthy narrative conclusion on Wednesday, January 10.

Olly was just 15 months old when he sadly died in March 2020, having been treated with Calpol, Ibuprofen and his parents handed Difflam throat spray for a viral infection.

He sadly died at his Bellemonte Road, Frodsham home early on March 23, found by his mum Laura Stopforth. A post-mortem examination found he had invasive group A strep, with a secondary cause of a viral respiratory tract infection.

Here is the jury's narrative conclusion in full:

"Olly had been blue-lighted to Countess of Chester Hospital on 20 March 2020 having consulted with the GP earlier that day and suspected to have a viral infection. The ambulance service pre-alerted the hospital to concerns about possible sepsis. Olly was admitted and treated for a viral infection and discharged home on 21 March.

"A comprehensive assessment and handover from the paramedic was given in A&E to nurse, paediatrician and GP specialist trainee, whereby sepsis was identified as being suspected. This was vocalised and noted in patient record forms. Observations were deemed grossly abnormal and that of a very sick child.

"The paediatrician then completed a rapid assessment (due to pressures of two other red alert patients). Whilst Kawasaki, meningitis and septicemia were discounted at this time, nothing was specifically done to rule out a bacterial infection, nor was a comprehensive plan put in place for reassessment.

"The Countess did not follow NHS UK sepsis tool or NICE guidance which, if used, would have indicated the need for blood test and/or IV antibiotics.

"In conclusion, the adequacy and thoroughness of assessment was not sufficient. Had these been sufficient, Olly's chance of survival would have been highly likely.

"All observations undertaken in A&E were abnormally high, with continued dry nappy due to insufficient fluid intake. The rash was considered to be as a result of a viral infection. Adequate assessment and continued observation was not undertaken. In summary, the above consideration of the observations would have triggered indication of blood tests or IV antibiotics should a screening tool have been used.

"As a result of the paediatric assessment, a treatment plan was documented. Whilst in A&E, other than administering paracetamol, the fluid challenge was not done nor was throat spray given. The treatment plan did not consider the timely re-address of bacterial assessment as advised should have been done by the expert witness. Therefore the plan was inadequate and not thoroughly followed.

"Upon transfer to the ward, the assessment undertaken by ST4 paediatrician was inadequate in that only and end-of-bed assessment was undertaken and no further assessment was taken after reading Olly's notes or before discharge.

"The only failing in the observations on the ward from a nursing perspective was the assumption around level of fluid intake. The inadequate communication of the treatment plan between A&E and the ward resulted in the requested fluid challenge not being started or monitored.

"The delay in transfer to the ward resulted in a lack of specific paediatric nurse care and a missed opportunity for earlier thorough assessment by ST4 paediatrician which may have increased Olly's chance of survival.

"Discharge should not have been given until Olly's observations were sustained beyond one set of [normal] figures. This was confirmed by the expert witness (paediatrician intensivist).

"There were a number of missed opportunities throughout Olly's care:

  • "Disparate information and no collective picture.
  • "Lack of/poor communication between staff.
  • "No tests to rule out bacterial infection.

"Whilst it is accepted that Covid 19 was amending the way things were done, the overall level of care that Olly received was inadequate and had tests been undertaken to identify a bacterial infection, Olly's survival would have been highly likely."

In a statement read by medical negligence solicitor Diane Rostron, on behalf of Karl and Laura Stopforth outside Cheshire Coroner's Court following the conclusion of the inquest on Wednesday, January 10, they said: "Olly's parents wish to thank the jurors and the coroner for recognising that Olly deserved better – so much better than he received, and that his precious life mattered.

"They are forever heartbroken at the loss of their beautiful boy."

Dr Nigel Scawn, medical director at the Countess of Chester Hospital NHS Foundation Trust, said: “On behalf of the Trust I would like to extend my sincere condolences to Olly’s family. We appreciate that any inquest is incredibly difficult for the loved ones involved.

“More investigations should have been done while Olly was in our care to fully diagnose and treat the underlying cause of his illness. The Trust has considered this in detail, and lessons have already been learned as a result.

“We have further embedded Local and National Guidelines in our work to help staff better identify and treat sepsis, including how to recognise when to administer antibiotics if sepsis is suspected.”