Telford baby death: Doctors could face action over failings

The trio have been referred to the General Medical Council (GMC) as health chiefs admitted some members of staff "could have performed better" when dealing with tragic tot Oliver Sargent.

But Andrew Tapp, women and children's care group medical director at Shrewsbury and Telford Hospital NHS Trust, said staff were "personally and professionally devastated" by what had happened to the baby.

It comes as the findings of a serious case review by Telford & Wrekin's Safeguarding Children Board were published yesterday.

It said "questions should have been asked and investigations undertaken" by doctors and nurses who spotted bruises on Oliver's body on four different occasions in the months leading up to his death.

Each time, medical professionals accepted the explanations from his parents Paul Thomas and Ashlea Thomas, who were found guilty by a jury at Birmingham Crown Court earlier this year of causing his death.

The reasons included Oliver being hit in the face by the tail of their Dalmatian dog Rocky, rolling over his toys and kicking the bars on his cot.

He died in July 2012, four days after he was rushed by ambulance to the PRH following a 999 call in which his father said he had stopped breathing.

Investigations after his death found he had suffered injuries which one expert described as consistent with being involved in a 40mph car crash. They included a fractured skull and bleeding on the brain. The serious case review report said Oliver would have "experienced aggression and violence which would have been both distressing and exceptionally painful".

Mr Thomas was jailed for 10 years after being found guilty of Oliver's manslaughter by a jury at Birmingham Crown Court at the start of April.

Ashlea Thomas, previously Sargent, was found guilty of a lesser charge of causing or allowing the death of a child and given a two-year suspended jail term.

The serious case review said a "comprehensive assessment" should have been undertaken by medical staff.

It accepted such an assessment "may not have prevented the fatal injuries" but said the "situation at home may have been improved".

Doctors at the hospital were also criticised for not being aware of key research which stated less than one per cent of bruises suffered by children who are yet to start walking or crawling were accidental.

Mr Tapp, speaking at Telford & Wrekin Council's Addenbrooke House headquarters as the report was made public, said no-one had been disciplined internally as a result of the probe.

But he added: "The GMC is carrying out its own independent review and the trust awaits the outcome of this."

Lessons have been learned, says health chief

Health chiefs at Telford's Princess Royal Hospital say lessons have been learned in the light of the Oliver Sargent tragedy.

A serious case review published yesterday by Telford & Wrekin's Safeguarding Children Board said "questions should have been asked" by doctors when they discovered bruising on his back and legs.

Instead they accepted the explanations put forward by his parents Paul and Ashlea Thomas, who were later convicted by a jury at Birmingham Crown Court of causing his death.

It has emerged three of the doctors at the hospital have been referred to the General Medical Council (GMC) and could face action.

Andrew Tapp, women and children's care group medical director at Shrewsbury and Telford Hospital NHS Trust (SaTH), which runs the PRH and Royal Shrewsbury Hospital, said the death of Oliver was "tragic". "The treatment of children in our care is paramount," he said.

"Therefore it is right that we, along with every agency who came into contact with Oliver and his parents, reflected on this case to ensure lessons that needed to be learned have been.

"At SaTH, in the months following Oliver's death a number of changes were made in practices and procedures to address those issues raised in the serious case review.

"Among these changes, any incident where there is the suspicion that injuries may be non-accidental is recorded using a body map to show the position of the injuries, along with measurements and full details."

Mr Tapp added: "A system has also been established to ensure that clinical photographs are taken 24-hourly on the children's ward.

"This improved recording of injuries ensures a more timely referral to social care should the situation arise.

"Should there be any difference of opinion between doctors about the nature of a child's injuries, the opinion of a dedicated named or designated doctor, who specialises in child protection, is sought.

"The trust continues to regularly review the systems in place for all cases of possible abusive injuries to ensure that these practices work correctly.

"We will continue to work hard, both within our trust and with our partners, to ensure children who come into our hospitals receive the best care and attention possible and, where concerns are raised, ensure that appropriate action is taken."