Family concludes 10 year fight for answers in baby’s tragic death

24/02/25

At the culmination of a three week inquest into the death of baby Benjamin Condon, who died while still premature at Bristol Children’s Hospital in 2015, Assistant Coroner Robert Sowersby held pseudomonal superadded infection should be added to the cause of death originally recorded 10 years ago.  He held that antibiotics should have been given to Ben, and that the failure to administer them made more than a minimal contribution towards his death.

Amongst the serious criticisms made in his conclusions, Assistant Coroner Robert Sowersby found that:

1. The University Hospitals Bristol and Weston NHS Foundation Trust took a “patronising approach” to Ben’s parents.  They were not told what was going on or why, nor were they involved in decision making, which was “manifestly wrong”. 
2. That there was clearly an “unacceptable delay” in giving antibiotics even when the decision was made to do so.
3. As to the Trust’s reaction to Ben’s death “[a] lot of mistakes were made, and things were said that shouldn’t have been, and steps were taken that shouldn’t have been”.  The Coroner held that the Trust’s approach “only served to exacerbate” the family’s distress. 
4. That Ben had been frequently hypothermic before his death, which was significant, and that he was surprised that it was of so little concern to the consultants.  Similarly, that the significant air leaks in Ben’s ventilation were of concern.
5. That a number of the consultants involved were not doing all that they could do to assist the Court and instead were defensive and evasive.  He held that there was an overall picture that the consultants did not realise how unwell he was until it was too late.

He also noted in his findings of fact that the Trust has issued a full public apology, and has accepted that Ben should have been given antibiotics and would probably have survived had it done so. 

The Coroner’s conclusions have been extensively reported: see e.g. here,  here, and here.