Autistic boy, 11, died of sepsis that was not spotted in time – inquest

A boy who had autism died of sepsis after hospital staff failed to spot the condition in a timely fashion, an inquest heard.

Mattheus Viera, 11, was described by medical staff as “uncooperative” and “very difficult to examine” during Tuesday’s hearing in Norwich.

The youngster, of Gaywood in Norfolk, was admitted to the Queen Elizabeth Hospital in King’s Lynn on the evening of April 11 2022 while suffering from a urinary tract infection.

But Mattheus, who had communication difficulties, did not like to be touched and would sit in his pram looking at his tablet computer.

Yvonne Blake, area coroner for Norfolk, said: “He wasn’t writhing about – he was sitting quietly playing and people might have been reassured by that.”

She said that Mattheus could communicate in single words – saying the word for “shoe” in Portuguese when he wanted to go out.

His diet largely consisted of crisps and he liked to watch the same cartoons at the same time of day, the hearing was told.

The coroner said the “seriousness of his condition wasn’t apparent to the staff who saw him”.

He died on the afternoon of April 12 as his condition worsened and as staff were preparing to transfer him to a paediatric intensive care unit in Cambridge.

Recording a narrative conclusion, the coroner said: “Mattheus died from sepsis which was not recognised in a timely fashion, and appropriate treatment was not instigated.

“His death was contributed to by neglect.”

His parents, Vitor Vieira and Maria Ferreira, attended the hearing and appeared tearful at points, with proceedings briefly adjourned mid-way through the day after Ms Ferreira collapsed.

She recovered and the hearing continued.

In a statement read by the coroner, Mr Vieira said: “He didn’t like being touched by strangers and the presence of lots of strangers made him stressed and upset.”

Mr Vieira, who works as a machine operator at the hospital where his only child Mattheus died, said: “Mattheus was our life and incredibly loved and our world has fallen apart without him in it.”

A serious incident investigation by the hospital recorded that a number of “red flags” for sepsis had been present, including Mattheus’s breathing rate, heart rate, low levels of oxygen in his blood and ashen appearance.

The coroner said that if Mattheus had been started on a sepsis pathway “in a timely manner, Mattheus would have survived”.

She continued: “It’s made difficult by children with Mattheus’s kind of condition where he can’t tell people how he feels.

“He doesn’t like people touching him so you get the difficulties, but you can’t just not take readings on people because it’s difficult.”

She extended her condolences to the boy’s parents, adding: “Thank you for the grace and courage you’ve displayed during this distressing time.”

Lucy Mellor, a specialist medical negligence solicitor at JMW, who is representing Mattheus’s parents, said afterwards: “The disturbing lack of treatment for Mattheus leaves no doubt in my mind that a finding of neglect was the only reasonable outcome from today’s hearing.

“What happened to Mattheus is shocking to all, but particularly for families with autistic children, and this has to be a watershed moment to ensure this can never happen again.”

Mr Vieira said afterwards that Mattheus “deserved the same standard of care as any other little boy but was denied this due to being autistic”.

“We want him to now have a voice, and for other autistic patients to be seen and to not needlessly lose their lives,” he said.