Two-month-old Ben Cordon died after antibiotics weren’t given until after cardiac arrest, inquest hears

A two-month-old baby died after antibiotics weren’t given until after he suffered a cardiac arrest, an inquest has heard. Ben Condon died at Bristol Children’s Hospital in April 2015 while being treated for a respiratory illness.

An inquest in June 2016 recorded Ben’s death as being caused by acute respiratory distress syndrome (ARDS), metapneumovirus (hMPV) and prematurity, however, the following year University Hospitals Bristol and Weston NHS Foundation Trust admitted a failure to give Ben timely antibiotics contributed to his death. High Court judges quashed the original inquest conclusion in 2021 and ordered a fresh hearing, which began at Avon Coroner’s Court on Monday (February 3).

Ben’s parents, Allyn and Jenny Condon, spoke earlier this week to say the hospital “covering up” failings had a devastating impact on them, including his mother attempting suicide.

While undergoing treatment in the paediatric intensive care unit, on April 17 Ben’s condition deteriorated and he suffered two cardiac arrests before dying. Dr Jessica Spaull, who was a junior doctor on the unit, told the inquest on Thursday (February 6) she had been concerned about Ben that morning and had discussed this with his parents.

She told the inquest she had a conversation with a consultant after the mid-morning ward round to give Ben antibiotics. “I cannot recall any details of what I said but I recall the conclusion was that it would be reasonable to start Ben on antibiotics,” she said.

“I recall I was in the process of doing that (writing up the prescription) when another of my allocated patients… when their endocrinal tube was accidentally removed. I recall I went over to that bed in an emergency, and I recall that I was involved reintubating that patient. That meant I had not completed that prescription at that point.”

The inquest has heard that Ben, from Weston-super-Mare, North Somerset, suffered the first of two cardiac arrests that afternoon and died later that evening. Dr Spaull told the hearing that later that day while completing a handover with the medical staff working the evening shift, she realised the antibiotics had not been administered.

“I recall looking at the drug chart and realising that the antibiotic prescribed earlier hadn’t been given,” she said. “I mentioned this to one of the bedside nurses who had attempted help with the resuscitation. I recall mentioning to one of the other junior doctors.”

Jennifer MacLeod, representing the Condon family, asked Dr Spaull whether there was a “level of complacency” about how poorly Ben was. Dr Spaull said this question was hard for her to answer as at the time she was a junior doctor only five weeks into her first placement on a paediatric intensive care unit.

“For me, I had heard Ben’s parents were worried, and I was worried about Ben’s oxygenation in particular that morning,” she said. “I think I would have judged how worried to be based on the experienced team’s assessment. I do not think I can comment on the specific question.”

She added: “I think that while I was not experienced in ARDS, I was able to make an assessment of a patient in intensive care as that was what I had been doing for the past five weeks, but also on a neo-natal intensive care unit prior to that. I recall having dialogue about my patients that I was concerned was.

“I think I would have made an assessment, which would have been appropriate for a junior doctor on the unit to make, and I think I would have discussed that assessment with a consultant in an open dialogue because they were present. In terms of specifics I can’t recall those conversations.”

Ben’s father Allyn Condon – a former Olympic sprinter – read a lengthy statement to the court on Tuesday (February 4) detailing his son’s treatment and death, followed by the family’s fight for information from the hospital where he died.

Mr Condon and Ben’s mother Jenny, from Weston-super-Mare, Somerset, said: “Losing a child is a tragedy in any circumstances. But in this case, that tragedy has been compounded by the fact that we have at all stages been faced with a failure to be transparent and straightforward about the circumstances that led up to Ben’s death.”

Mr Condon said they had suffered “years of grief, anger and frustration”, with them both having post-traumatic stress disorder. All we have ever wanted is the truth,” he said.

“We really hope that this inquest will finally answer some of the remaining questions that we have regarding Ben’s death and lead to an accurate account of what happened to Ben and the mistruths we were told afterwards.”

He later told the hearing: “The extent of the harm caused to us as a family by not being provided with correct information about the death of our baby cannot be underestimated. “We have been unable to grieve, heal and move forward because we do not have the basic information needed to process Ben’s death. This has been made so much worse by the actions of the trust over the past 10 years.

“We have often felt that the trust have treated us with contempt and that there has been a desire to protect the reputation of the trust and its staff above all else, and without any concern as to the impact taking this approach has had on us as a family.

“What should have been a compassionate and candid approach to Ben’s death by the trust has been defensive, hostile, obstructive and adversarial from the outset and continues to be so even through this process.”

Mr Condon said Ms Condon was in an “extremely fragile state of health” and accused the trust of continuing a “hostile, obstructive and defensive approach”. He added: “It is inhuman.”

The inquest heard that Ben was born in February 2015 at 29 weeks gestation and spent seven weeks in neonatal intensive care at Southmead Hospital. He was discharged on April 7 but developed a cold and a runny nose, and three days later his parents took him to Weston General Hospital before he was transferred to Bristol Children’s Hospital the following day.

The inquest continues.