THE Countess of Chester Hospital gave "inadequate" care for a Cheshire toddler, with missed opportunities to detect a bacterial infection, an inquest jury has found.

Olly Stopforth was just 15 months old when he sadly died less than 48 hours after being discharged from the hospital in March 2020, having been treated with Calpol, Ibuprofen and his parents handed Difflam throat spray for a viral infection. 

He sadly died at his Bellemonte Road, Frodsham home early on March 23, found by his mum Laura Stopforth. A post-mortem examination found he had invasive group A strep, with a secondary cause of a viral respiratory tract infection.

The three-day inquest at the Cheshire Coroner's Court in Warrington, before coroner Jacqueline Devonish, heard evidence from Olly's mum, father Karl Stopforth, Countess staff and independent medical experts, with hospital staff admitting more should have been done to treat the toddler for signs of sepsis, where blood tests and administration of antibiotics would likely have saved Olly's life.

As part of a lengthy narrative conclusion, the jury said: "Whilst it is accepted that Covid 19 was amending the way things were done, the overall level of care that Olly received [at the Countess] was inadequate and had tests been undertaken to identify a bacterial infection, Olly's survival would have been highly likely."

Previously, the inquest heard after Laura Stopforth made an NHS 111 call on March 20, due to Olly having a very high temperature, a rash, no appetite and looking lethargic, an ambulance was deployed and blue-lighted Olly to the Countess of Chester Hospital. North West Ambulance Service paramedic Lynsey Field, recording a temperature of 40.7C and a heart rate of 202 beats per minute for Olly, suspected sepsis.

But although that concern was relayed to hospital staff on Olly's arrival at 5.30pm, it was not formally followed up on.

Olly was assessed by paediatric consultant Dr Alison Timmis at 5.45pm in what she later told the inquest was "never intended to be a full and formal assessment", as at the time three children - including Olly - had been admitted to A&E and all potentially required immediate emergency treatment. The final assessment was expected to happen on the paediatric ward transfer.

A&E staff nurse at the time Lauren Stanton told the inquest she believed Olly's rash, which was "extremely red" and "shocking" was a sign Olly had scarlet fever, but she could not recall relaying that to doctors.

Olly and father Karl waited more than five hours for the paediatric ward transfer to take place - the delay due to a lack of nursing staff. After the transfer, Olly was assessed by paediatric registrar Kieran McCarthy at 11.30pm. 

He told the inquest that at this time, Olly's rash was widespread and did not look like scarlet fever, and suspected a viral infection. He fought back tears on Tuesday as he was shown a photo of Olly taken at 7.20pm, where he said the rash looked more like scarlet fever at that point.

Olly was discharged following one set of normal observations taken at 2am, with Dr McCarthy telling the inquest the decision to discharge at that time was made due to the onset of the Covid pandemic, with patients more at risk the longer they stayed in hospital.

The onset of coronavirus had also led, the inquest heard, to difficulties with hospital staff wearing additional PPE and distancing, meaning hands-on care for patients was limited.
Independent medical expert Dr Mary Montgomery told the inquest nothing was done to rule out a bacterial infection for Olly, and clinicians made lots of assumptions, with documents unclear.

Olly Stopforth's parents had brought different photos of Olly, displayed in front of them, for the 10 jurors to see on each day of the inquest.

All Countess staff who gave evidence at the inquest offered their apologies and condolences to the Stopforth family.

Coroner Jacqueline Devonish thanked the parents for their show of strength and dignity throughout the three-day hearing, and offered her condolences.