C died aged only a few days old. The mother had sustained a spontaneous rupture of the membranes at 36 weeks and had attended a hospital. She had not been given antibiotics and had been discharged. C was born by emergency caesarean section a few days later and despite displaying signs of illness, was not treated for many hours. They have since uncovered a number of other deaths, which are now the subject of a police investigation.

C was killed when cycling a bicycle along a main thoroughfare. C struck a pothole and was thrown to the ground sustaining fatal injuries. The family are pursuing a personal injury claim on behalf of the estate of C and dependents.

C (a child, deceased) was admitted to hospital with symptoms of illness but was discharged with advice to return if there was a significant deterioration. C was taken back to hospital 3 days later and sustained life changing injury as a result of Meningitis. I was instructed by the NHS trust to represent their medical practitioners who attended.

As an Assistant Coroner I conducted this inquest. C sustained a small bowel infarction and perforation, which had not been discovered for some time. C was eventually admitted to hospital where surgery took place and they initially made some improvement. Sadly, C’s condition took a turn for the worse and they deteriorated and passed away. The family were concerned about the delay in diagnosis and treatment. I entered a conclusion of natural causes.

I was instructed in this high profile case by the family when the Coroner indicated her intention to conclude the inquest. Upon review of the papers it became clear to me that C had been referred to hospital by their GP with signs of meningitis (lethargy, aching, rash, headaches, vomiting, fever) but was met with a diagnosis of food poisoning. I attended at the inquest and following detailed submissions the Coroner agreed to refer the matter to the police. The police have instructed their own medical experts and their investigation is ongoing .