Jury concludes baby should not have been discharged

Six-month-old Hunter Martin died after being discharged from hospital with chicken pox

An inquest jury has concluded a six-month-old baby who died with chicken pox should never have been sent home from hospital.

Hunter Martin was later mistakenly given an overdose of antibiotics - ten times the prescribed amount, on five separate occasions.

However, the Derbyshire coroner ruled there was not enough evidence the drugs blunder contributed more than minimally to Hunter's death.

Bosses at Chesterfield Royal Hospital say it is now looking at 23 different areas of improving its care.

Jade Smith and Alex Martin, Hunter's parents said they felt "massively let down" by the NHS

Following an inquest at Chesterfield Coroner's Court, a jury concluded Hunter died due to sepsis and Group A Streptococcus infection linked to chicken pox.

In addition, it was found his death was contributed to by the decision to discharge him from hospital on 4 March 2023.

The inquest identified two occasions where Hunter's condition could have been escalated sooner to critical care.

He was eventually transferred to Sheffield Children's Hospital two days after his parents, from New Whittington, first took their son to Chesterfield Royal Hospital Accident and Emergency. Hunter died after suffering three cardiac arrests.

He had been mistakenly given an overdose of antibiotics, ten times the prescribed amount on five occasions when he was brought back to Chesterfield by his worried parents - the day after he had initially been discharged.

The jury heard instead of the recommended dose of 94mg of Clindamycin, Hunter received 940mg.

Coroner Peter Nieto directed the jury there was not enough evidence to show that mistake more than "minimally" contributed to Hunters death.

Speaking after the inquest, his parents said they felt "massively let down" by the hospital over their son's death.

Hunter's father Alex Martin said: "We are always going to be left wondering what impact this [antibiotic] actually had, because we've not had any solid answer on that. It's what if?"

His mother Jade Smith said: "It's heartbreaking, and to relive it all for a week, just to find out what we already knew."

'Missed opportunities'

In a statement read during the proceedings, Chesterfield Royal Hospital NHS Foundation Trust said ibuprofen had been given to Hunter, which went against its guidelines for treating chicken pox.

It admitted this "probably masked the early signs of his infection", adding that Hunter should have had a clinical review and remained under observation for longer.

The trust's statement added that this "false reassurance" led to a missed diagnosis of Group A Streptococcal infection on Hunter's first admission.

It added: "It is admitted that, on the balance of probabilities, had the bacterial infection been suspected and treated with IV antibiotics by 14:30 on 4 March, Hunter would have survived.

"However, it is accepted in hindsight that there were later missed opportunities to recognise worsening features of sepsis and escalate care to tertiary intensive care, this is due to the mixed picture of Hunter's observations and clinical status."

The trust offered a "profound" apology to Mr Martin and Ms Smith, adding it had "identified areas that required improvement" to prevent similar incidents in the future.

The family is working to raise awareness of sepsis and recently held a fundraising event in their home village.

They have also liaised with local hospitals for posters featuring Hunter to be placed in A&E and paediatric departments urging people to look for the symptoms.

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