Written evidence from Thong Nguyen
3.1. “The inquest process is of profound importance to many families. It can have a huge impact on the grieving process. A properly conducted inquest which exposes the truth, culminates in a finding about what went right and what went wrong, and makes recommendations for change if that is necessary, can help relatives to recover after a death. Conversely, a poorly conducted inquest can have quite the opposite effect and may cause serious and permanent damage.” - Leslie Thomas QC
7.1. Reform must be anchored upon placing bereaved families at the heart of the system. My own experience has been the exact opposite and I submit that I have at times been treated with outright hostility and disdain by the Coroner’s Service.
7.2. To facilitate more accountability and consistency, Coroners should be funded by the central Government and we should establish a National Coroners Service. Unchecked “independence” and the disunion between funding and governance has resulted in unclear lines of accountability. My impression is that Coroners operate like sheriffs from the “old west”. They are in-charge of their own town or “area” and are a law unto themselves; effectively accountable to no-one.
7.3. There should be uniform standards, training and regular appraisals for both Coroners and Coroner’s officers. Training programmes should emphasise empathy and compassion as well as adherence to national guidelines to ensure consistency.
7.4. We must unreservedly concede the adversarial nature of inquests and provide non-means-tested funding for bereaved families whenever there is a state-related death. There is just no way around the fact that inquests are adversarial.
7.5. Appeals to the Chief Coroner should be made available. The power of a Coroner’s ruling profoundly affects not only justice but the grieving process itself and failures can cause long lasting damage. We should strengthen the powers of the Chief Coroner and reintroduce legislation permitting appeals directly to the Chief Coroner. Easier access to appeals would also serve as a check-and-balance for individual Coroners.
7.6. The Coroner “area” system risks conflicts of interest when there is a state-related death. A Coroner’s area will cover specific state-run institutions such as prisons and hospitals that, overtime, will build a strong relationship with the court and may result in unintended bias against family. When there is a state-related death, families must have the option to nominate their Coroner.
8.1. “There were opportunities for the pathophysiology to be reversed by early intravenous fluid resuscitation with on-going assessment of the efficacy of treatments given (heart rate, blood pressure, urine output) via close continuous bedside monitoring and effective use of early-warning scores as adjuncts to clinical decision-making. There was a need for cardiovascular and respiratory support, and a clinical indication for non-resident paediatric and PICU resources and experience via consultations with CATS, and these were not accessed by the resident paediatric team to assist and guide management in an effective and timely way.” - Chelsea & Westminster SUI report
9.1. “Hayden did not receive a reasonable standard of care at the Chelsea & Westminster Hospital.”
9.2. “There was a persistent failure to recognise the severity of his condition, to intervene in a timely fashion, to monitor appropriately, and to refer to Paediatric Intensive Care in a timely fashion.”
9.3. “There was a failure of the Consultant Paediatrician to take a lead role in Hayden’s case.”
9.4. “There was a failure to follow the Chelsea & Westminster guidelines with reference to recording observations for paediatric patients.”
9.5. “The escalation protocol re the Chelsea and Westminster guideline for response to the PEWS was not followed.”
9.6. “There was an overall persistent failure to appreciate the severity of shock and the progression of Hayden’s shocked state.”
9.7. “Importantly there was a failure to respond in terms of diagnosis, frequency of investigation, and escalation of care to Hayden’s blood gas results, full blood count results, and standard observations.”
9.8. “At 01.32 hours the pH was significantly low at 7.06 and the lactate had risen further to a significantly high level of 7.5. Hayden was also in respiratory failure with a pCO2 level of 10.7. There is just no way that the Clinicians involved in Hayden’s care can claim that he was not a very ill child.”
9.9. “Dr Penny disagrees that the appropriate response would have been for intubation and further bolus fluid, call for Anaesthetic support, consultation with other Senior Members of the Team and liaison with CATS for transport to PICU care, and preparation to support with inotropes. In my opinion all of the above measures were necessary if the Inquest accepts all the clinical records barring those of Dr Penny.”
9.10. “The literature on shock in young children emphasises that in the stages of compensated shock the baby/child can still appear reasonably well. Dr Penny should have been aware of this.”
9.11. “Dr Alexander says that Dr Penny and the Registrar thought that the picture was not one of septic shock. Given the prolonged capillary refill time, the persistent tachycardia and tachypnoea, the low platelet count and the blood gas analysis results, it is difficult to understand the conclusion of Dr Penny and his Registrar.”
9.12. “By around 02.00 on 25 August 2016 Hayden had deteriorated further; he was described as ‘mottled++’ with a capillary refill time of 3 seconds centrally and peripherally, was ‘grunting intermittently’ and had not passed any urine since midnight. This clinical deterioration was confirmed by the repeat capillary blood gas performed at 01.32 which demonstrated extreme physiological derangement and indicated the need for immediate aggressive resuscitation.”
11.1. “He’s breathing fast, CO2 should be low so he’s not actually managing to lower his CO2 and that's mysterious. It was another one of his symptoms, certainly, that was high but it's not so much you could, oh, yeah, this is that symptom, this is what that means, but it just makes me worry because you then have to think why is this symptom here. Which would prompt me to put him straight onto an intubator because he’s got a pH of 7, CO2 of 10, he’s breathing at 80 and much faster than he can breathe and the CO2... The next pH is below seven, and it carries on like that and below seven and he's going to arrest.” - Dr Jegede (Consultant Paediatrician & Consultant Paediatric Intensivist), Inquest Day 3
11.2. “This patient didn't have, unless I'm mistaken, any fluid with the first gas for the reasons that have already been described which I accept, so then you have a gas which is worse, significantly worse. Even if it's just one gas, the only gas you ever took you would then look back, or I would look back, and think, okay, at that gas the lactate was four, even though this child looks well this is a significant deterioration. So I'm not just looking at the one gas and focusing on it, I'm thinking well, the child was recognised as being unwell, continued to be unwell, the unwellness was confirmed because someone did the gas and actually the gas showed quite a significant deterioration in terms of what's happening internally with that child in terms of the physiology of the child which doesn't necessarily have to be displayed externally. That’s why you do gas because otherwise we could go on what we find physically by examination. We use all of these things as agents to inform us about what's happening to the child.” - Dr Jegede (Consultant Paediatrician & Consultant Paediatric Intensivist), Inquest Day 3
11.3. “At 01.32 hours the pH was significantly low at 7.06 and the lactate had risen further to a significantly high level of 7.5. Hayden was also in respiratory failure with a pCO2 level of 10.7. There is just no way that the Clinicians involved in Hayden’s care can claim that he was not a very ill child.” - Dr Conway (Consultant Paediatrician)
14.1. “By the time Hayden had been admitted to Mercury Ward at around 23.00-24.00 he had deteriorated from a cardiovascular perspective, was clearly in shock and required immediate aggressive resuscitation. Dr Kemi Bako was negligent in not recognising Hayden’s clinical status at around 23.00-24.00 and in not facilitating immediate aggressive resuscitation. It is my opinion, on the balance of probability, that had Hayden received appropriate treatment at around midnight on 24-25 August 2016 then he would have been stabilised to the degree that he could have been transferred to a Paediatric Intensive Care Unit and would have survived.” - Dr Playfor (Consultant Paediatrician, Consultant Paediatric Intensivist)
14.2. “Dr Jonathan Penny was negligent in not recognising Hayden’s clinical status at around 02.00 and in not facilitating immediate aggressive resuscitation. It is my opinion, on the balance of probability, that had Hayden received appropriate treatment at around 02.00 on 25 August 2016 then he would have been stabilised to the degree that he could have been transferred to a Paediatric Intensive Care Unit and would have survived.” - Dr Playfor (Consultant Paediatrician, Consultant Paediatric Intensivist)
14.3. “From my clinical experience caring for critically ill children, and integrating the data that we have regarding the time course of Hayden’s deterioration it is my opinion, on the balance of probabilities, that had Hayden received appropriate treatment with aggressive intravenous fluid resuscitation, intubation, mechanical ventilation and the administration of inotropic agents prior to 04.00 on 25 August 2016 then he would have survived.” - Dr Playfor (Consultant Paediatrician, Consultant Paediatric Intensivist)
14.4. “I concur with Dr Playfor’s review of the literature that over 50% of children will survive. Therefore it is my opinion that Hayden would have survived with appropriate intensive care on the balance of probabilities.” - Professor Burch (Consultant Paediatric Cardiologist)
15.1. “The expert identified that Dr Penny’s standard of care was seriously below the expected standard in respect of his failure at 0145 on 25 August to: document his assessment and management plan for Hayden and his discussion with Hayden’s parents; recognise and treat metabolic and lactic acidosis due to circulatory failure; seek advice from paediatric intensive care team about Hayden’s deterioration and clinical status; stay with Hayden and ensure timely management, reassessment and escalation. If other commitments meant that he was unable to stay, Dr Penny’s failure to contact the non-resident consultant for immediate assistance was seriously below the expected standard.” - GMC report on Dr Jonathan Penny
15.2. “The expert identified that Dr Penny’s standard of care was below the expected standard in respect of his failure to treat profound acidosis (at 05.15 on 25 August) in a timely way with immediate advice from paediatric intensive care team and potentially, dependant on skill set, to act immediately to intubate and ventilate Hayden. The expert said that Hayden was extremely unwell and that the real opportunity to intervene and stabilise Hayden had passed. He noted that there was a 35 minute delay in contacting the paediatric intensive care team for advice and that no action other than an intravenous fluid bolus was taken between this time and Hayden’s cardiac arrest at 06.00.” - GMC report on Dr Jonathan Penny
15.3. “The expert (an experienced consultant paediatrician) said that the standard of care provided by Dr Penny to Hayden on the night of 24 and 25 August 2016 fell seriously below the standard expected of a reasonable competent paediatric consultant in relation to the assessment, decision making, urgency of care, leadership/handover, follow up and documentation.” - GMC report on Dr Jonathan Penny
16.1. “The letter of response on behalf of the Trust dated 2 September 2019 should be read as a full admission of liability on behalf of the Trust in relation to the tragic death of Hayden at 07.15 hours on 25 August 2016. The expert evidence obtained on behalf of the Trust indicates that had the severity and progression of Hayden’s condition been recognised and acted upon earlier, he would have survived beyond 07.15 hours on 25 August 2016” - Weightmans / NHS Resolution, 23 September 2019
17.1. “No admissions to be made by the Trust, given the criticisms made of the SI report at the inquest” - Harbens Kaur (former Head of Legal for the Trust), post-inquest briefing, 5 February 2018
18.1. "The real scandal actually of the Hayden case is that it took 3 years to reach a decision about the cause of the loss of his little life. He was on this Earth for 6 days and it took us 3 years to work out the Hospital got it wrong.” - Former Health Secretary Stephen Dorrel, BBC R4 Today, 21 January 2020
19.1. "Dr Davis[sic] is clear that with the information she had at the time of writing the SI report, which included statements from staff, information from both you and your wife and the clinical notes, her opinion was correct at the time, she is very clear as Lesley and I were when we met with you that the original SI still stands and the action plan is monitored in the trust" - Pippa Nightingale (Chief Nurse, C&W Hospital), 3 April 2019
21.1. “That was a very strange position for us to be in. I have to say I’ve never been in a place where we’ve had to take legal advice under a request from a Coroner cause it was quite a strange request to come ... hence why we didn’t quite understand actually what we were being requested to do… and we were very intentional in not repeating the whole review and the SI report because we felt very strongly that shouldn’t do that. We can’t just remove something that we put and signed ourselves to and write a new one.” - Pippa Nightingale (Chief Nurse, C&W Hospital), 6 September 2018
22.1. “A key issue the family raised was how they felt they were treated by the coronial system. They felt that the ‘system’ including the coronial system caused more pain and distress and raised new questions rather than answering critical ones.
I understand from the family that they are seeking a new inquest. Such matters are for the coronial system, but it is clear to me that the way families are treated by the coroners’ system can have a lasting impact on them. It would be helpful to understand what efforts are underway to support bereaved families so that the process can feel less adversarial than it did to this family.
I also understand that, in this particular case, the coroner raised concerns about the Serious Untoward Investigation conducted by the NHS. This would seem to me to be unusual in terms of commenting on an investigation process which is designed to identify areas for improvement. This warrants further consideration as to how the health and coronial systems work together to ensure that learning from such serious incidents is maximised. I would value the opportunity to discuss formally.” - Rt Hon Matt Hancock MP, SofS for Health and Social Care, 28 May 2019
23.1. “It may be that the Coroner’s motivation in asking our SI team to reconsider their conclusions may be to try to limit the amount of evidence that needs to be called to satisfactorily conclude the inquest (or possibly to avoid the inquest at all if, but for the possible shortcomings, this was a natural death). At the moment there are conflicting opinions on whether the care was satisfactory, and unless our SI team review their conclusion the Coroner is going to have to explore these at Inquest to reach a conclusion. This will mean calling the expert at the coroner's expense, plus a longer inquest no doubt involving the SI report's main author. If the SI is revised then this all goes away for the coroner, so long as it is properly explained to the family.” - Harbens Kaur (former head of legal, C&W Hospital), 13 June 2017
24.1. Failing to understand how the PEWS (paediatric early warning score) policy actually operated. The Coroner misunderstood the rationale behind the scoring system, mistakenly attributing to “sleep” what is actually an AVPU score which does not score for sleep but scores for alertness and thereafter referring to the PEWS "in real terms" by repeatedly and wrongly subtracting 1 from every PEWS score attributed to Hayden and thereby excusing the lack of escalation. By 02:30, Hayden’s PEWS score had reached 5 (out of 6) indicating need for paediatric and anaesthetic review and consideration of a crash call. The Coroner wrongly asserted that this score was not five but instead was four “in real terms”.
24.1.1. The Coroner further excused the need to perform AVPU assessments by stating “babies need rest and sleep”. She did not smirk while making this statement but nevertheless I found it very hurtful given the context. My comment here is that Hayden was seriously ill, required continuous monitoring, was fading in and out of consciousness, and is now permanently at rest.
24.2. Upon comparing the changes to the PEWS policy before and after Hayden’s death, the Coroner mistakenly interpreted the changes to have included more flexibility and diminished the criteria for escalation when in fact the opposite was true. It is unclear whether she truly misread the changes (saw what she wanted to see), but leaning on this mistaken interpretation, she postulated that the changes were perhaps to allow more clinical judgement (thereby guarding clinicians who fail to escalate against criticisms in the future). The PEWS policy had actually been fortified. It added a new requirement for urgent registrar review when systolic blood pressure < 70 (regardless of other scores), changed the level 4 colour-coding from yellow to red and mandated following the “highest action” if there were discrepancies in guidelines.
24.2.1. One of a Coroner’s core duties is to issue Regulation 28 reports (PFD: prevention of future deaths). I submit that the Coroner’s proclamations and actions with regards to PEWS policy and the SUI amounted to a GFD (guarantee of future deaths). Had it not been for the Trust choosing to ignore her, more deaths from failures to identify and act on deteriorating babies in shock would have been almost certain.
24.3. Not allowing the SUI author to give their own independent evidence but instead led them to simply agree with the Coroner’s interpretation of events which, in fact, was very different to the scenario which had been presented in the original SUI. The transcript shows great swathes of narrative from the Coroner, almost invariably followed by a “Yes” from the SUI author. This resulted in the contention by the Coroner that it was "shocking" that the SUI report was with NHS England and that it was "clearly not reflecting the evidence" and that it should be “removed from the record”.
24.4. Before allowing interested parties to question the SUI author, the Coroner criticised the author’s peer-reviewed work stating: “I feel that the SI findings do not quite reflect the clinical picture nor, indeed, do they reflect the considerable input by senior members of staff at all times in his care while he was in their care”.
24.5. Wrongly adopting the preposterous argument made by the Consultant and his barrister that Hayden’s outward “appearance” was equivalent to Hayden’s “clinical picture” when in fact, as noted by all independent experts qualified to comment (including that of Dr Jegede who gave oral evidence at the inquest), Hayden’s “clinical picture” was of a seriously ill baby in shock and respiratory failure.
24.5.1. “I’m thinking well, the child was recognised as being unwell, continued to be unwell, the unwellness was confirmed because someone did the gas and actually the gas showed quite a significant deterioration in terms of what's happening internally with that child in terms of the physiology of the child which doesn't necessarily have to be displayed externally. That’s why you do gas because otherwise we could go on what we find physically by examination. We use all of these things as agents to inform us about what's happening to the child.” - Dr Jegede (Consultant Paediatrician & Consultant Paediatric Intensivist), Inquest Day 3
24.5.2. “At 01.32 hours the pH was significantly low at 7.06 and the lactate had risen further to a significantly high level of 7.5. Hayden was also in respiratory failure with a pCO2 level of 10.7. There is just no way that the Clinicians involved in Hayden’s care can claim that he was not a very ill child.” – Dr Conway (Consultant Paediatrician)
24.5.3. “The literature on shock in young children emphasises that in the stages of compensated shock the baby/child can still appear reasonably well. Dr Penny should have been aware of this.” - Dr Conway (Consultant Paediatrician)
24.5.4. “By around 02.00 on 25 August 2016 Hayden had deteriorated further; he was described as ‘mottled++’ with a capillary refill time of 3 seconds centrally and peripherally, was ‘grunting intermittently’ and had not passed any urine since midnight. This clinical deterioration was confirmed by the repeat capillary blood gas performed at 01.32 which demonstrated extreme physiological derangement and indicated the need for immediate aggressive resuscitation.” - Dr Conway (Consultant Paediatrician)
24.5.5. “I really do not understand the argument that as Hayden had disseminated enteroviral infection and associated myocarditis there exists a defence for the failure to treat him aggressively for a picture of shock. The diagnosis was not known at the time. By virtue of the clinical picture alone Hayden needed full and much earlier Intensive Care.” - Dr Conway (Consultant Paediatrician)
24.6. After robust questioning by the Dr Penny’s barrister whereby the SUI author was pressed to suggest that a new SUI report needed to be written, the Coroner feigned shock and stated that it should be made “very clear to NHS England that the previous reports be removed from the record”. I suggest that the Coroner’s shock was not real because we now know that it was the Coroner herself who had urged the Trust to consider a new SUI report in the months leading up to the inquest. I also reiterate that the Trust has since stated, unequivocally, that its board and the SUI author stand by the original SUI and that no new report will be written.
Following the aforementioned robust questioning by the Consultant’s barrister, the NHS Resolution solicitor stated “I’m not sure how much more I can add” which was followed by the Coroner, smirking and stating “I thought that might be a sensible approach”. This left us staggered.
24.7. Allowing Dr Penny’s barrister to demand an apology for the clinicians including Dr Penny himself. This was particularly grotesque considering it was performed in-front of us and the Coroner, again, smirked as it happened. Dr Penny would later use this event to claim that the Coroner herself had asked the SUI author to apologise to him when defending his misconduct to the GMC.
Imagine attending your own child’s inquest, hoping (but not expecting) to receive an apology from the clinicians who failed him only to have to watch in horror as the clinicians themselves receive a specious apology in-front of you for being “upset” at warranted criticisms their own employer had made of them.
24.8. Theatrically picking up her pen and scribbling out the SUI action plan (a plan intended to ensure learning) stating that point 10 “should go” because she didn’t want the clinicians to have to go through appraisals with clinical governance. The Coroner was (or should have been) aware that the action plan had already been completed almost 12 months prior. The Trust insists they had shared this fact with the Coroner and distanced themselves from this particularly shameful act.
24.9. Failing to integrate any of Dr Jegede’s evidence into her findings. In a letter to our MP (Ruth Cadbury), our solicitor wrote:
24.9.1. “As an advocate-who, incidentally, was given no opportunity to make any oral submissions following all the oral evidence- it was abundantly clear to me that the Coroner had essentially prepared her conclusion prior to the start of the final day’s evidence from Dr Davies and Dr Jegede. I formed that view based upon the approach adopted to questioning Dr Davies and the fact that immediately following Dr Jegede's evidence the Coroner read out her conclusions without incorporating any of that evidence. That that impression was equally clear to the family is regrettable. The family should have felt they were at the heart of the inquest process: that was certainly not the case here and they formed the view that issues had been pre-determined.”
25.1. (1) An acknowledgement that Hayden existed and that his care fell seriously below expected standards, and that he died having not received the care he deserved as a citizen of the United Kingdom. There is legal significance as to whether Hayden, due to neglect or negligence, lost a 51% chance of survival or a 49% chance of survival. However, for any parent, an unnecessary loss of a 49% chance of survival would still be devastating; the Coroner appeared to be incognisant of this and devoid of empathy.
25.2. (2) That learnings would be made to prevent future deaths.
27.1. Only days after Hayden’s death, the Coroner’s officer, unprompted, described over the phone in gruesome detail how my son’s autopsy would be performed. Describing how his brain and other organs would be removed and examined. Tact and sensitivity were lacking.
27.2. Inquests are to be held within 6 months of death, but Hayden’s inquest was not held until almost 15 months after his death. I recognise here that this is not unusual and understand many courts are under pressure.
27.3. The Coroner initially did not even agree that there should be an inquest into Hayden’s death notwithstanding that the duty to do so was clear under s4 (2) (a) Coroners and Justice Act 2009. The Coroner knew the Trust was conducting a serious incident investigation but the week before the report was due to be released, the court notified us that Hayden’s case was to be closed without an inquest. It was only following representations by our lawyers supported by the Trust’s position that the death was potentially avoidable that led to a review of that decision.
27.4. Inquests are court proceedings and I was to give evidence. I thus expected a formal invitation, but one was not sent - digital or hardcopy. This was unexpected and gave me an impression of disorganisation and unprofessionalism. Given our experience with the Trust, it was an unwelcome reminder.
27.5. The Coroner’s officer shared with me that the expert instructed by the Coroner to comment on care and causation was given only a selection of the evidence provided by the Trust. I found this odd given neither the Coroner’s officer nor the Coroner are general paediatricians and so were not qualified to decide the relevance of select evidence. I believe Coroners should provide all available evidence to experts.
27.6. The Coroner’s officer insisted that all communications to the court should come through legal representatives rather than directly. I understand the desire for formality, but I do not think this ethos is proper; especially given the gravity of the situation and the Chief Coroner’s position that the family should remain at the heart of the system.
27.7. At the pre-inquest review hearing, it was conceded by the Coroner that the expert she had instructed to comment on care (Dr Martin) was not appropriately qualified. It was agreed that Dr Conway’s report would be shared with Dr Martin so that he could have a fully informed picture of the care in order to properly comment on causation. It was not until the day before the inquest that we were informed that Dr Martin had not been provided with a copy of Dr Conway’s report. We do not know whether this was deliberate or a mistake.
27.8. The Coroner’s officer offered to return Hayden’s tissue samples with his body for burial. We notified the officer that a cryogenics company would collect the tissues for storage. Thus, began a two-month saga whereby our cryogenics company chased the court and St Thomas’ Hospital for Hayden’s tissues (St Thomas’ performed Hayden’s post-mortem). During this period the Coroner’s officer stated that he did not know why the tissues were not being released and attributed the delays to St Thomas’ Hospital. Eventually the Coroner’s officer admitted that he himself had asked St Thomas’ Hospital to withhold the tissue samples. His bungling explanation was that there was a past unrelated case that had required further examination of tissues and having remembered that prompted him to withhold Hayden’s tissues. This explanation and the manner in which it was given did not appear sound but, in any case, it cannot excuse two months of dishonesty and deception. We would have agreed to yield Hayden’s tissues for 2 months or 2 years had it been explained, and had we been asked.
27.9. We were unaware that the Coroner assigned to Hayden’s case had changed from Dr Fiona Wilcox to Dr Shirley Radcliffe until we encountered Dr Radcliffe at Hayden’s pre-inquest hearing. Disclosures from the Trust show that the Trust was kept apprised of these changes but we, the family, were not.
27.10. Following the inquest, I wrote a heart-felt letter of concern to the Coroner and was told by the Coroner’s officer to expect an answer within two weeks. It’s been almost 3 years without an answer.
27.11. During the inquest, the Coroner almost invariably referred to Hayden as “the baby” or “this baby” rather than by his name or “baby Hayden” – an approach I felt dehumanised Hayden.
27.12. We were charged £1500 for the transcripts to our son’s inquest (£500 per day). After mild scrutiny, I discovered that legislation (Coroners Allowances, Fees and Expenses Regulations 2013) clearly outlines fees that may be charged for court transcripts and calculated that we had been overcharged by ~30% (£500). It took a year of back and forth before the court conceded and offered a full refund. The Coroner would not share if this had happened to other families nor explain how it had happened to us. According to the Trust, they were not likewise billed and I’m unaware whether other interested parties were likewise billed.
1 September 2020
 , Inquests: A Practitioner's Guide
 Lesley Watts, Trust CEO