A coroner has ruled that a little boy with Down's syndrome died of natural causes, despite highlighting a "catalogue of errors" in his treatment.
Lydia Brown, assistant coroner for Leicester and South Leicestershire, criticised doctors and nurses in the treatment provided for Krishan Saujani at the end of a five-day inquest at Leicester Town Hall yesterday.
The three-year-old, who had Down's syndrome, died on November 8, 2015, from bronchial pneumonia - a day after being taken to Leicester Royal Infirmary with vomiting and diarrhoea.
The court heard how Krishan had a weakened immune system and was more vulnerable to infections due to his condition.
Mrs Brown said that on an "exceptionally busy" Saturday night for the hospital's accident and emergency department, there was a "lack of communication between doctors and nursing staff".
She also criticised a "delay in transferring Krishan to the hospital's CAU (clinical assessment unit)". The inquest heard how Krishan was waiting on a trolley bed in the hospital's emergency department for up to three hours before finally being transferred to a bed on the CAU at 3.30am.
The coroner said there were "delays in the investigation and treatment of Krishan's condition" and a failure to administer the antibiotics he desperately needed until only a few hours before his death, shortly before 8am.
Mrs Brown said hospital staff should have listened to Krishan's parents' growing concerns about their son's deteriorating condition.
However, in reference to evidence provided by Andrew Furlong, medical director at Leicester’s Hospitals, she said she was satisfied by improvements made at the Infirmary to prevent future deaths.
Improvements as part of the hospital's new, £48 million accident and emergency department, which opened last April, include new electronic systems to monitor critically ill children in extremely busy periods. New procedures have also been adopted to ensure the appropriate staff can be moved to cover different parts of the hospital where they are needed the most.
