An independent review into the death of a three-year-old boy at Stafford Hospital will examine whether there should be a second inquest after its terms of reference were expanded, HSJ has learned.

  • Consultant paediatrician asked to widen investigation after parents met Jeremy Hunt
  • Key staff will be questioned along with a review of evidence documents
  • CCG review ordered after parents said there was a “cover up”

The investigation is being carried out by consultant paediatrician Martin Farrier, an associate medical director at Wrightington, Wigan and Leigh Foundation Trust. It was launched by Stafford and Surrounds Clinical Commissioning Group following the death of Jonnie Meek in August 2014.

His parents, John Meek and April Keeling, believe their son’s death has been the subject of a cover up, with false statements and inaccurate medical records and testimonies supplied to a child death overview panel and coroner’s inquest.

They had an hour long meeting with health secretary Jeremy Hunt at the end of September. A week later the CCG confirmed new expanded terms of reference for the review.

Dr Farrier was originally asked to carry out a case note review of Jonnie’s care on the day that he died, but he is now undertaking a more detailed investigation including interviews with staff and addressing his parents’ concerns.

Jonnie was born with the rare congenital condition de Grouchy syndrome and was lactose intolerant. He died in August 2014 just over two hours after being admitted to hospital to trial a new milk feed fed directly into his stomach.

His parents believe he died after suffering a reaction to the feed, which caused him to vomit and then suffocate after doctors and nurses ignored Ms Keeling’s concerns. An inquest into his death in January recorded a verdict of natural causes as a result of pneumonia.

Since then his parents have obtained records suggesting a child death overview panel received a false statement in the name of a healthcare assistant, Lauren Tew, who was with Jonnie when he died at Stafford Hospital’s children’s unit. She told HSJ last month that the statement was wrong and she had never made it.

Other records his parents believe are false suggest Jonnie was admitted to hospital and was critically ill just months before his death and that he had suffered two or three previous cardiac arrests. His parents are adamant both claims are false.

The terms of reference for Dr Farrier’s review, seen by HSJ, include:

  • providing an opinion on the cause of death;
  • providing an opinion on whether there is sufficient evidence for a second inquest;
  • examining whether care was delivered in line with recognised best practice; and
  • identifying lessons learned and recommendations for reducing the risk of similar outcomes in the future.

Dr Farrier will also consider how the complaint by Jonnie’s parents was handled and whether the review supports the findings of the coroner’s inquest and the separate child death overview panel.

Mr Meek said the new terms of reference were an improvement and he welcomed the fact it would consider the case for a new inquest and the process followed by the child death overview panel.

He added: “The original review by the CCG was only going to look at the notes from the day Jonnie was in hospital. The CCG seems willing to do a proper job now and I am a bit more confident about it.

“The important thing is that the CCG and the trust act on the findings of the review.”

A Department of Health spokeswoman said: “Our deepest sympathies are with Jonnie’s parents on their tragic loss. On 30 September the secretary of state for health met Jonnie’s parents and their representatives to hear their views on the best way to investigate the concerns they have about their young son’s death.

“As a result of them raising these concerns, the local NHS has appointed a leading expert in paediatric care to carry out an independent clinical review of Jonnie’s care. Consequently, it would not be appropriate for us to comment further, until this investigation is complete.”