Parents win battle to find out how their baby died in hospital

Parents who spent a decade campaigning for answers about their baby's death said the findings at his second inquest were "everything we fought for."

Eight-week-old Ben Condon died in 2015 at Bristol Children's Hospital, six days after being admitted with breathing difficulties.

Allyn and Jenny Condon were dissatisfied with an inquest held in 2016, and fought for a second hearing believing antibiotics could have prevented his death.

The Divisional Court quashed original inquest into Ben Condon’s death on 20th October 2021 and ordered a new inquest as its findings, based on evidence available to the coroner at the time, did not mention a bacterial infection or of the potential relevance of antibiotics.

It was only afterwards, following a civil claim brought by Allyn Condon, that the trust accepted that there had been a bacterial infection and that earlier prescribing of antibiotics could have prevented the baby’s death.

In erasing the original inquest, the Divisional Court said that the trust’s’ change of position undoubtedly constituted new evidence, and that it was possible that a different conclusion could be reached in a subsequent inquest.  It did not accept the trust’s claims that this would discourage the settlement of civil claims.

At the most recent inquest, assistant coroner for Avon, Robert Sowersby, recorded a new cause of death as acute respiratory distress syndrome (ARDS), pseudomonas bacterial infection, metapneumovirus (hMPV) and prematurity.

He also found the administration of surfactant, given to assist Ben's lungs, contributed to the baby developing an air leak into his pericardium and then suffering a cardiac arrest.

Mr Sowersby criticised the "patronising" approach of Bristol Children's Hospital towards Ben's parents and said it was "manifestly wrong" they were not informed or consulted about procedures that carried risks to their baby

The assistant coroner also reached a number of damning conclusions about the care Ben Condon received and found a bacterial infection had been a cause of his death, but it could not have been prevented.

During the inquest, Ben's parents described how his temperature kept falling below targeted levels and he was frequently hypothermic.

The coroner said: "The fact that a seriously unwell baby was allowed to drop well below a targeted temperature seems to me to be significant."

He added that he could not conclude that this, or the management of Ben's ventilation, contributed to his death, but was "still a concern."

Mr Sowersby added that the overall picture of Ben's care suggested "the consultants looking after Ben didn't realise quite how unwell he was until it was too late."   

The coroner said the decision to give Ben a third dose of surfactant on 17 April carried "significant potential risks", but this was not discussed with his parents, which he described as "manifestly wrong.”

He added: "This was part of what seems to me to be a patronising approach to Ben's parents in which they were not told what was going on, or why, and nor were they included in decisions around Ben's treatment."

Mr Sowersby added that there was an "unacceptable delay" in giving Ben antibiotics prescribed on the day of his death.

He also criticised the communication with Ben's parents, who were told at 18:30 BST that day that their baby may not survive.

He said: "It is very hard for me to understand how it could have taken this long for them to have been told this stark fact."

After reading his conclusion, Mrs Sowersby said: "I hope Ben's family can take some element of pride in what they have achieved in their battle for the truth. Perhaps most important of all, the changes the trust has made in recognition of the areas where they didn't care for Ben as well as they should have."

Speaking after the verdict, Ben's parents thanked the coroner for the "thorough review", calling it "a basic human right we should have been afforded a decade ago.”

They said: "We are grateful that the trust stands by their position that their failure to prescribe earlier antibiotics contributed to Ben's death and that on the balance of probabilities, had they treated him with antibiotics earlier, he would have survived."

During the inquest a document appeared to suggest that four swabs were taken from Ben's body and sent for tests in the 48 hours following his death despite his parents being assured that there was no need for their baby to undergo a post-mortem examination, leading to his body being cremated.

They added: "We will be contacting the General Medical Council and the Human Tissue Authority to trigger the process for a potential criminal investigation under the Human Tissue Act 2004.

"We will continue to fight until we are sure no other family will have to face the irreparable pain and suffering we have had, and are still having, to endure."

In a statement, hospital managing director at University Hospitals Bristol & Weston NHS Foundation Trust, Prof Stuart Walker, apologised and said: "We have undertaken significant learning and reflection in the 10 years since then.

"We accept the conclusion of the assistant coroner, and I would again like to acknowledge the distress experienced by Ben's family."