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A five-week-old baby died from tuberculosis contracted from his dad after medics dismissed the tot's symptoms as a common lung infection.
Luchii Gavrilescu, from Margate, died at the QEQM on December 6, 2019, from what was thought to be sepsis caused by bronchiolitis.
But during a six-day inquest held in Maidstone it was heard little Luchii had actually caught TB which his dad, Vlado Gavrilescu, had been unknowingly living with. This is despite a lesion showing up on an x-ray of Mr Gavrilescu's lungs in March 2018 at the William Harvey in Ashford.
The baby's mum Laura Cooke had continuously tried to get Luchii treated in the week leading up to his death but was sent home twice, despite red flags pointing to a life-threatening condition.
The inquest heard how on November 29 she went to the QEQM with Luchii who was suffering with a mottled rash, a snuffly nose, erratic breathing and reduced feeding.
He was seen by two junior doctors in the A&E department, diagnosed with bronchiolitis and sent home without further treatment - despite the first doctor recognising that further investigation was necessary.
On December 3, Miss Cooke went back to the hospital with Luchii after being referred by her GP, who thought the baby had a chest infection and should be seen by a paediatric doctor.
Instead he was seen by an advanced nurse practitioner who considered his observations to be normal and sent him home with a diagnosis of resolving bronchiolitis.
Three days later, the day Luchii died, he was taken in by ambulance with erratic breathing, apnoea and a period of floppiness.
But it was heard at the inquest that the seriousness of Luchii’s condition was not picked up quickly enough, meaning a lack of escalation to a more senior doctor at an earlier stage.
This was due to failures at handover, a failure of senior paediatric medical staff to attend the A&E department and an unsafe transfer between ward and theatre without a stable airway.
Sadly, after multiple resuscitation attempts, Luchii died that day.
Hospital chiefs admitted afterwards that his death was "avoidable", with a damning report revealing staff failed to recognise the severity of his symptoms and did not escalate the case to consultants, who were completely unaware of Luchii and his grave condition.
A post-mortem was carried out which then determined Luchii’s cause of death was not sepsis, but actually disseminated tuberculosis infection and lymphocytic myocarditis.
Following this revelation, Mr Gavrilescu was then himself diagnosed with TB.
A report by the East Kent Hospitals Trust confirmed the "significant delay" in Mr Gavrilescu's diagnosis led to Luchii and others - including Miss Cooke, her two other children Archie and Macie, and family friends - being infected.
The catalogue of failings were admitted by hospital chiefs during a civil case held last year.
During the inquest, the trust accepted that, on the balance of probabilities, had Mr Gavrilescu's TB been identified and treated in 2018, then Luchii would not have contracted the disease and his death would not have occurred.
Professor Parviz Habibi, an expert brought in by coroner Joanne Andrews, found that at no point did Luchii’s presentation on November 29 or December 3 fit the clinical signs of bronchiolitis. The professor said had Luchii undergone senior clinical review by a paediatric registrar or consultant, he would have been admitted and undergone investigations as to the cause of his worsening symptoms.
However, he could not say that on the balance of probabilities Luchii would not have died but for the failure to admit and treat him on those dates.
After six days of evidence, the inquest into Luchii’s death concluded that the baby died due to natural causes as part of the natural progression of TB.
It was noted that it was likely that it was his dad's TB, which was undiagnosed, that was passed to Luchii and culminated in his death.
During the hearing, East Kent Hospitals said they had learned from Luchii's death and have made substantial changes to their paediatric practice, producing 59 action points.
These include stressing to staff the importance of senior paediatric review both in light of clinical deterioration and before the discharge of a baby, ensuring sufficient staffing of the paediatric team and changes in how handovers between paediatric medical staff take place.
Speaking after the inquest, Miss Cooke paid tribute to the legal team for helping her navigate the "complicated and heart-wrenching process".
"Although I am glad the trust has made admissions regarding both Luchii and Vlado’s care it will never bring my little boy back and that is something Vlado and I will have to live with for the rest of our lives," she added.
Francesca Beach of Fairweathers Solicitors, who represented the family, says it has been a truly difficult experience for the family having to relieve the painful memories.
"However it has also been extremely important for them to hear from the medical staff that were involved in their son’s care and also have their fears regarding that care confirmed by a coronial expert.
"Given that the trust admitted liability in the civil case so early on, there was a risk that they would not get the most out of the inquest due to lack of representation. However counsel, James Robottom of 7BR, kindly agreed to appear pro-bono alongside me and that has been invaluable in securing the answers to the outstanding questions the family had."
Dr Rebecca Martin, chief medical officer for East Kent Hospitals said: "Our thoughts and deepest sympathies go out to Luchii’s family on their devastating loss.
"We accept the conclusion of the jury.
"Luchii’s condition is extremely rare, but staff caring for children now have additional training and we have put in extra safety checks before children are discharged.
"We have also made improvements to the way unwell children are monitored.
"Changes have been made to how X-rays are reviewed with an additional check for underlying conditions such as TB."
