Inquest Touching the Death of Leo Stacey
The Luton and Dunstable Hospital was subject to criticism by a coroner during the inquest into the death of 10-month-old Leo Stacey.
Leo died on 6 October 2015 as a result of a rare bowel condition.
Prior to his death, he suffered from sickness and dehydration. His mother Nathalie Aubrey-Stacey and father Mark Stacey, first became concerned on 4 October 2015 when Leo began vomiting. He was taken to an out of hour’s clinic in Hemel Hempstead where a GP made a diagnosis of probable gastroenteritis was made. Medication was prescribed. However, his condition continued to deteriorate and by the next evening Leo’s parents noticed blood in his vomit. He was taken by ambulance to the Luton and Dunstable Hospital.
Upon Leo’s arrival at the hospital, A&E staff noted that he appeared to have a distended abdomen. Doctors repeatedly attempted to insert an intravenous line into a vein to provide fluids to rehydrate him but they were unable to do this successfully.
Leo’s condition continued to worsen and he passed away following unsuccessful resuscitation attempts by staff before he could be transferred to Great Ormond Street Hospital for specialist care.
An autopsy was later carried out by Dr Jeremy Price at Great Ormond Street and it was discovered that Leo had a prolapsed bowel. He had suffered from a viral infection and died from ileocecal intussusception; a rare bowel condition. He also noted that Leo’s body weight was 14% less than when he was last weighed, which was indicative as to his level of dehydration.
Coroner Martin Oldham delivered a narrative verdict. With regard to the team who treated Leo upon his arrival at the hospital, he stated:
Sadly they did not address his hydration or solve the dehydration fully until he died.
The hospital’s locum consultant paediatrician Dr Ranjith Joseph insisted that staff:
“..did [their] best to save Leo’s life”. He added that “In hindsight and unpicking things there wasn't enough fluid, but this was not something we realised."
Leo’s mother told Ampthill Coroner’s Court that the hospital had failed to ensure that her son was hydrated and there had been a delay in transferring him to Great Ormond Street Hospital. She added:
“I firmly believe that if Leo had received competent and timely care, he would not have died and Marc and I and the rest of the family would not have been left scarred and devastated by these events.
There was ample information that Leo needed to be referred to a paediatric surgeon but this was not done in a timely manner.
At the conclusion of the inquest The Luton and Dunstable Hospital apologised for their failings in a statement:
“We would like to extend our condolences again to Leo's family, following his death in October 2015.
We have carried out a full investigation into how Leo died and have met with his family to discuss the outcome. It is clear there were failings in his care for which we have sincerely apologised.
"There were a number of recommendations that came out of the review, all of which have been implemented, with the learning shared across the Trust. These include the introduction of new guidelines in relation to fluid administration and the management of cardiac arrest in children".
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