Eight week old baby Ben Condon died at Bristol Royal Hospital for Children on 17 April 2015 having developed acute respiratory distress syndrome following a bacterial infection.
An inquest into Ben’s death was held in 2016 at which the coroner was told by doctors from the Trust that the bacterial infection and the treatment of it was not connected to Ben’s death. The coroner gave a narrative verdict recording the factual circumstances of the death.
Ben’s parents complained to University Hospitals Bristol NHS Foundation Trust about aspects of the care Ben received and in 2017 the Trust apologised for making mistakes. His parents remained unhappy with the Trust’s response and escalated matters, complaining to the Parliamentary and Health Service Ombudsman about the care Ben received.
The Ombudsman investigated and last week published its report into the complaint. It found that the Trust did not recognise how poorly Ben was early enough and “did not provide him with the treatment he needed as promptly as they should have done”. It found that Ben and his family suffered serious injustice as a consequence of the failings in Ben’s care and treatment. It described these failings as lost opportunities “to intervene and give Ben the best possible chance of recovering from his illness”, observing that “Each one of the failings would have reduced the chances of the best possible outcome for Ben.”
Commenting on the investigation, Ombudsman Rob Behrens stated:
“Our investigation found a catalogue of failings in the Trust’s treatment of Ben Condon, which meant several missed opportunities to give him the best possible chance of recovering from his illness. Mr and Mrs Condon now have to live with the knowledge that Ben’s care was sub-standard and that each failing reduced his chances of recovery. We also found failings in the way the Trust communicated with Mr and Mrs Condon, exacerbating a highly distressing situation over an extended period of time. This is every parent’s worst nightmare and they deserved better from those they trusted with their child.
The injustice of never knowing whether things might have been different is something they will have to live with forever.”
You can read the full report of the Ombudsman here:
Ombudsman comments on investigation into the death of Ben Condon | Parliamentary and Health Service Ombudsman (PHSO)
According to a report in The Guardian, following the Ombudsman’s findings, Ben’s parents are seeking to have the high court annul the inquest into Ben’s death.
This very sad case raises important legal issues. In particular, the duty of candour. Doctors have long had an ethical and professional responsibility to advise patients to be open and honest about mistakes made in their treatment. There has also, since November 2014, been a legal duty of candour requiring NHS Trusts to advise patients of mistakes leading them to suffer harm.
Although the duty of candour is now a legal one, in our experience the duty of candour is, sadly, not always exercised as it should be.