Inquest into Toddler’s Death Reveals Missed Sepsis Diagnosis and Neglect

Howells Solicitors represented the family of 16-month-old James Philliskirk at Sheffield Coroner’s Court, where an inquest found that missed sepsis symptoms and failures in hospital care contributed to his death.

Overview of the Inquest

Howells Solicitors acted for James Philliskirk’s family during an inquest investigating the circumstances surrounding his death at Sheffield Children’s Hospital.

The inquest examined concerns about delayed diagnosis, failures in clinical assessment, and whether appropriate treatment was provided.

A jury concluded that James’s death was contributed to by neglect following a misdiagnosis, raising serious concerns about patient safety and clinical decision-making.

Background: Repeated Concerns Dismissed

James, aged just 16 months, was taken to Sheffield Children’s Hospital twice on Thursday 12 May 2022 following advice from his GP.

His parents raised concerns that he was seriously unwell, presenting with symptoms including:

• – Skin lesions
• – Lethargy and food refusal
• – Groaning noises
• – A high fever of 38.5°C

Despite these warning signs, hospital staff repeatedly diagnosed James with chickenpox, even though he had already suffered from the illness two weeks earlier.

Failure to Recognise Sepsis

Evidence heard during the inquest confirmed that James was, in fact, suffering from sepsis caused by a Group A Streptococcal (Strep A) infection.

Key concerns identified included:

• – Failure to consider sepsis despite clear symptoms
• – No documented review by senior medical staff
• – Emergency Department guidelines not being followed
• – No reconsideration of the original diagnosis despite worsening symptoms

The inquest also heard that there was no record of clinicians questioning the likelihood of a repeat chickenpox infection.

Missed Opportunities to Escalate Concerns

Further evidence revealed multiple missed opportunities to escalate James’s care:

• – A GP raised concerns about possible Scarlet Fever, which were shared with the hospital but dismissed-
• – A 111 call handler’s concerns about James’s condition were not acted upon
• – A significant skin lesion linked to earlier illness was not recorded or investigated

These failures highlighted significant breakdowns in communication between healthcare professionals.

Deterioration and Death

James’s condition did not improve after being discharged home.

Approximately 32 hours after his hospital visits, he was found unresponsive by his father in the early hours of Saturday 14 May 2022. He was pronounced dead at Sheffield Children’s Hospital at 2:08am.

The inquest confirmed that earlier diagnosis and treatment of sepsis may have altered the outcome.

Prevention of Future Deaths Report

Following the inquest, Assistant Coroner Abigail Combes issued a Regulation 28 Prevention of Future Deaths (PFD) report, identifying six actions for Sheffield Children’s Hospital NHS Trust.

The Trust is required to respond with a detailed action plan addressing these concerns, aimed at preventing similar tragedies in the future.

Hospital Investigation and Identified Failures

A Serious Incident Investigation conducted by Sheffield Children’s Hospital NHS Trust also identified failures in care, including:

• – Breakdown in referral processes between GP and hospital
• – Failure to follow Emergency Department clinical guidelines
• – Lack of senior clinician review
• – Inadequate documentation of symptoms and diagnosis

These findings reinforced the concerns raised during the inquest.

Family’s Response

James’s family described him as a “fun, happy, cheeky, and active little boy” who brought joy to everyone around him.

They expressed the devastating impact of his loss and their determination to ensure lessons are learned to protect other families.

In James’s memory, the family have led a number of initiatives, including:

• – Supporting the 4Louis charity
• – Installing a memorial bench and plaque
• – Funding play equipment in his memory

They continue to work with organisations involved in James’s care to drive improvements in patient safety.

Legal Representation at the Inquest

The family were represented by Howells Solicitors’ specialist inquest team, with Senior Inquest Solicitor Jenna Kisala supporting the family throughout proceedings.

Howells Solicitors commented:

“This is a truly tragic case, and our thoughts remain with James’s family. The findings of the inquest highlight significant failings in care.”

“We hope that the investigation, inquest conclusion and Prevention of Future Deaths report lead to meaningful improvements in children’s healthcare and communication between medical professionals.”

Support for Families Facing an Inquest

An inquest can be a complex and distressing process, particularly when concerns arise about hospital negligence, delays in diagnosis, or failures in medical care.

Specialist inquest solicitors can support families by:

• – Investigating potential failings in healthcare
• – Ensuring all relevant medical evidence is considered-
• – Representing families at Coroner’s Court
• – Helping families understand the inquest process and outcomes

Findings from the Inquest and Jury Conclusion

After a four-day inquest hearing, the jury returned a narrative conclusion, stating: “Following a number of assessments in hospital, James was misdiagnosed and was not provided with treatment in line with departmental guidance. He developed sepsis and died… His death was contributed to by neglect.”

This conclusion reflects serious failings in care and highlights the need for improved clinical practices in identifying and treating sepsis.

If an Inquest Has Opened

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