BBCA coroner has found neglect and failure to provide adequate medical care contributed to the preventable death of a baby.
Hayden Nguyen died aged six days at the Chelsea and Westminster Hospital in London in 2016.
The conclusion came after his parents spent seven years and £250,000 fighting for justice.
In a statement, the hospital said it was “committed to learning from any findings to improve our practices”.
Family handoutSenior Coroner Richard Travers said in his findings that Hayden had “obvious needs that were simply not met” by clinicians when his parents took him to the Chelsea and Westminster Hospital in west London in August 2016.
They were concerned about a fever he had but his condition quickly deteriorated. He had a cardiac arrest and died within 12 hours of arriving at the hospital. The treatment Hayden received, Mr Travers found, fell “very seriously below expected standards” and had he received appropriate and timely care, he would have survived.
An internal investigation by the hospital following Hayden’s death found there had been eight errors in the care he’d received, including failures to identify signs of septic shock and to act on abnormal test results.
However, the original inquest into Hayden’s death, held at Westminster Coroner’s Court in 2017, concluded he had died of natural causes.
The coroner, Dr Shirley Radcliffe, had contacted the hospital to raise concerns about their investigation.
The hospital produced a second report, which halved the number of errors found and said the root cause of Hayden’s death was an infection “which is known to have a high mortality”.
His parents were incensed by the coroner’s actions and felt they had to act. “It is the second worst experience of my life,” Hayden’s father Tum Nguyen, 44, said of the first inquest.
“Having to live with the injustice and the dishonesty has been really difficult, which is why the fight for having a second inquest has not really been a choice for us.”
Family handoutObtaining a second inquest required applying to the Attorney General’s Office for permission to go to the High Court to ask judges to overturn the original conclusion.
In December 2021, two High Court judges agreed that a new inquest should take place “in the interests of justice”.
While they did not find that the original coroner, Dr Radcliffe, had behaved in a biased manner, she was variously described by the judges as being “unwise” and “close to being intemperate,” with her questioning of one witness “close to the borderline between robustness and unacceptability”.
The BBC approached Dr Radcliffe for comment at the time, but she did not respond.
This second inquest, which the family described as being “thorough, detailed and compassionate”, took place over three weeks at Surrey Coroner’s Court.
The whole process, including the High Court challenge and legal fees has cost Hayden’s parents about £250,000.
“The cost doesn’t compare to the injustice,” said Tum, a social media executive. “So everything we did was completely right. I think it was incumbent on us to do it because I do know there are other families out there who can’t necessarily afford to do what we did.”
Family handoutHayden’s mother Alex, 48, who owns a software company, says other families may also be too immersed in grief to fight for answers.
“You are trying to deal with your grief, and when negligence is involved, that adds a whole extra layer that you then have to process. So for other families, it might not be possible financially, but also it might not be possible because of the grieving process.”
The couple believe the legal steps they took will allow other families to argue that coroners need to put the bereaved family at the heart of every inquest, allowing Hayden’s name to live on.
They also hope the second inquest will allow them to fully grieve the loss of their son. “The coroner has opened the possibility that we can put this to rest now,” said Alex.
“Having an honest appraisal of what happened on the night [Hayden died] and seeing the majority of the medical team involved actually be accountable and admit their errors and show that they’d made learnings was quite healing.”
Lesley Watts, chief executive for Chelsea and Westminster Hospital NHS Foundation Trust, said: “We are deeply sorry for the loss of baby Hayden and offer our condolences to his family during this time.
“We remain committed to learning from any findings to improve our practices and ensure the highest standards of care for every patient.”
