Inquest finds ‘neglect’ by Whipps Cross Hospital a factor in toddler’s death

The death of a three-year-old boy was contributed to by “neglect” in his care while at Whipps Cross University Hospital, a coroner has found.

Shaham Abu Aman, known as ‘Aman’, who lived in Ilford, had been taken to the Leytonstone hospital with vomiting and diarrhoea on December 7, 2021 and was later discharged with a suspected “tummy bug”.

Aman was sent home at 10.30pm, but the next morning his mother found he was unresponsive and rushed him to hospital, where he was pronounced dead.

An inquest held on Thursday September 1 at The Adult College of Barking and Dagenham heard a series of “missed opportunities” at the emergency paediatric ward meant his deteriorating state, likely to be severe dehydration, was not noticed.

In his verdict, coroner Graeme Irvine found that a “lack of communication” between the nursing and medical team led to his “inappropriate discharge”.

He added: “It is likely, on the balance of probability, that a different outcome would have followed.

“Neglect contributed to Aman’s death.”

Aman’s mother Sabana Begum Kamali, who attended the inquest with the boy’s father, said: “I’m very grateful that we have the NHS that can help us, but sometimes with cases like this they break our trust.

“It was not a very serious condition, if it was an operation theatre and some people tried to save him and couldn’t I would understand, but it was basic things, they just missed a simple step… and now this.

“Why wait for one incident to happen, why not fix it earlier?”

The day after Aman was born in June 2018, a malformation in his digestive system was discovered that required urgent surgery. For the next year Aman carried a stoma bag to allow his body to pass stool, but this was removed in October 2019.

On December 7, 2021, when Aman was taken to Whipps for vomiting and diarrhoea, the emergency department at the Leytonstone hospital was under high pressure, with 15 patients waiting more than an hour to be triaged and 27 admitted children waiting four hours for a doctor.

Dr Mohammed Zia, the Whipps Cross clinical director who carried out an internal investigation, described a “perfect storm” of issues that resulted in a “failure of collective communication”.

Giving evidence, he said: “This was much more than a busy shift, it was extremely challenging.”

A key missed opportunity in Dr Zia’s report was a failure to monitor exactly how much fluid Aman was retaining through an ‘oral fluid challenge’ which could have prompted doctors to put him on a drip, although the coroner accepted, Aman’s exact state of health was a “complicated picture” as his heart rate and blood pressure were not abnormal.

The high demand that night also meant there were no beds available in the high dependency unit and Aman was instead placed in a bed close to the nurses station.

Dr Zia’s report also identified a “mismatch” between the nursing team’s concerns that Aman looked “dreadful” and the views of the doctors who discharged him without requesting further observations.

Dr David Champion, who examined Aman personally, offered the family his condolences and said he had “reflected” on his role in events.

This included asking more senior registrar Dr Matthew Lim for advice, but not formally referring the case to him. Following the meeting, Aman’s vital signs were assessed using an automated warning system known as PEWS, which did not identify him as a high risk.

Ward sister Fatima Lewis, who was overseeing the nursing team, feared Aman was “severely dehydrated” but believed there was “a plan” by the time he was discharged.

She said: “I told Dr Lim that he had to see Aman as he is looking dreadful, the response to that was that Dr David [Champion] had already discussed the child with him.”

Nurse Lewis also felt there had been a miscommunication between herself and a ‘float’ nurse who provided a one-off “second opinion” instead of one-to-one care.

Dr Zia told the coroner the hospital has now introduced a specific training session based on the mistakes leading to Aman’s death, including tightening up the “disconnect” between nurses and doctors.

A written statement by Aman’s mother, read at the start of the inquest, described her fourth child as “a very special boy”.

She added: “He was a cheeky little boy who was loved so much, he was curious about the world around him, energetic and enthusiastic and would always play with us.”

Following the verdict, coroner Graham Irvine asked Barts Health NHS Trust, which runs Whipps Cross, to write to him within 28 days outlining how it will prevent future “failed discharges”.

He said: “I’m confident that the actions taken by the trust are appropriate, but my residual concern is that when all is said and done this was a child of three who should not have been discharged from hospital.

“Whatever the procedures in place, there was no way of putting the brakes on his discharge to allow careful consideration. He should have been kept in hospital and ultimately should have been moved to a [resuscitation] bed.

“At the back of my mind are numerous other cases about failed discharges from [the emergency department] with failed blood tests or other tests not being looked at.

“What [I am] looking for is a system or proposal about how discharge can be more safe.”

A spokesperson for Barts Health said: “We extend our deepest sympathies to the family of Shahan Aman at this difficult time and sincerely apologise for the failings identified.

“We will be responding to the coroner with the actions we are taking to prevent this happening again.”

Josh Mellor

Local Democracy Reporter