Clodagh Bradley KC, instructed by Stephen Jones, Partner at Leigh Day, appeared before HM Senior Coroner for Surrey, Mr Richard Travers, at a 3-week inquest on behalf of the parents of a baby, Hayden Nguyen, who was admitted at about 1930 hours on 24 August 2016 to Chelsea & Westminster Hospital severely unwell at 5 days of age with fever and reduced feeding. The Coroner concluded that he died at 0715 on 25 August 2016 as a result of natural causes contributed to by neglect because “the seriousness of his condition was entirely apparent… there were persistent failures, from about 2100 hours onwards, to provide or procure the medical attention and interventions he obviously needed, in breach of national and local guidelines for the management of paediatric sepsis”. The Coroner found that the failures over a number of hours were serious, ‘gross’ and denied Hayden ‘basic medical attention’. Hayden died of enteroviral myocarditis. His death would have been avoided with appropriate medical treatment.
The outcome of this inquest was a significant relief for Mr and Mrs Nguyen, after an unsatisfactory experience at Westminster Coroner’s Court before Dr Shirley Radcliffe in 2017 where a conclusion of natural causes only was made. Dr Radcliffe declined to hear from a consultant paediatric expert, Dr Steven Conway, who did give evidence at the second inquest. The parents successfully quashed the first inquisition in proceedings under section 13 of the Coroners Act 1988 in 2021 where Jay J noted some of Dr Radcliffe’s remarks to have been ‘unwise’, ‘close to being intemperate’ and some questioning coming ‘close to the borderline between robustness and unacceptability’ [105]. Further evidence from Dr Stephen Playfor, consultant paediatric intensivist, and Professor Michael Burch, Consultant Paediatric Cardiologist at GOSH, demonstrated the probability of Hayden’s survival with appropriate management.
By contrast, the parents told the BBC that the second inquest in the Surrey Coroner’s Court in 2024 was “thorough, detailed and compassionate.” They said, “Having an honest appraisal of what happened on the night [Hayden died] and seeing the majority of the medical team involved actually be accountable and admit their errors and show that they’d made learnings was quite healing.“
