Coroner Criticises Medical Treatment of Two Year Old

Coroner makes criticisms of medical treatment received by two year old prior to his death

On 18 February 2021, Dr Karen Henderson, assistant coroner for East Sussex, concluded the inquest touching on the death of Oscar Riley. Dr Henderson found that there was “a perfect storm of circumstances all of which contributed to lost opportunities in directing Oscar’s care, management, investigation and treatment.” Oscar collapsed and went into cardiac arrest on 19 December 2019. He was taken to St George’s Hospital where a brain tumour was found. Oscar successfully underwent surgery on 20 December 2019 in order to resect the tumour, however tragically he was found to have suffered catastrophic brain damage. Having been advised to do so by the health professionals, Oscar’s parents took the heart-breaking decision to remove life support treatment and he died on 24 December 2019, leaving his parents and 7-week-old brother. 

Oscar had suffered from repeat chest infections and often appeared to be choking when attempting to swallow. This led him to be miserable on a frequent basis with him appearing unhappy and not wanting to play. He suffered from what was deemed to be three febrile seizures which led to him being admitted to hospital. The inquest found that Oscar had been unwell for some time and that there were missed opportunities to explore his symptoms further. After an extortionate number of visits to the local GP throughout the year, Oscar had been admitted to the Conquest Hospital in Hastings on 6 September 2019, 9 September 2019 and 26 September 2019 with breathing / swallowing issues, but a cause of his issues was not identified. Oscar’s parents did not consider that his symptoms were being adequately considered and therefore paid for him to see a private paediatrician on 27 September 2019. He was prescribed some antibiotics and appeared to initially improve before deteriorating again by 18 October 2019. 

The private paediatrician referred Oscar to the Brompton Hospital for further review, however tragically due to an administrative error this was not sent. Dr Henderson found that the paediatrician did not have a robust system in place to prevent this from happening. Oscar had a further review at the Conquest Hospital on 17 October 2019 when a videofluoroscopy was arranged for 16 January 2020, a few weeks after Oscar died. 

Dr Henderson found during the inquest that there had been a failure to look at the whole picture in respect to Oscar’s condition, that there was a failure to consider neurological causes, and that there was a failure to listen to the concerns of the parents. Dr Henderson summed up the inquest by saying that “the absolute tragedy is that it is clear that an earlier diagnosis would have given the very real possibility for Oscar to be cured of this benign tumour.” Ben Davey, medical negligence lawyer of Dean Wilson Solicitors acting for the family said: “This is a tragic set of events that have led to missed opportunities to save a young boy. Whilst doctors cannot be expected to consider every condition immediately, it was very clear that Oscar was unwell and required urgent tests to diagnose his health conditions. No one professional took responsibility for driving his care forward and this has proved catastrophic on this occasion.” 

In a statement read out at the inquest Oscar’s parents, Ross & Emma Riley, said: “Oscar was our son. He was a beautiful little soul. His caring and warm nature was infectious. He was incredibly helpful and always wanted to please others around him and to make them smile. In the second year of his short life, we could see him changing. He was unwell a lot of the time, and we weren’t able to get him fixed, despite us promising him we will get him better. Even though Oscar was not well a lot of the time, he was still able to bring joy and warmth to others with his personality. We are still so heartbroken we are not able to see him grow into the wonderful young man he was becoming, but we enjoyed every single minute we had with him. It was a privilege. We will never forget him. Oscar has saved the lives of many other children through organ donation. His death has forced process changes within the healthcare system to help bring about faster diagnosis times. We hope sharing our story helps to raise awareness of the symptoms of brain tumours to save more lives. “ 

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