A coroner has ruled that the death of a severely autistic 11-year-old boy from sepsis, at Queen Elizabeth Hospital in King’s Lynn, was contributed to by neglect.

At an inquest held at Norfolk Coroner’s Court into the death of Mattheus Ferreira Vieira, coroner Yvonne Blake said:

“My narrative conclusion is that Mattheus died from septicaemia which was not recognised in a timely fashion and treatment was not instigated. His death was contributed to by neglect.

“Mattheus deteriorated throughout the day, eventually the seriousness of his condition was finally noticed. Whilst on his way to be intubated he went into cardiac arrest and died. It is accepted that the sepsis six protocol was not applied and that had it been done so in timely manner then Mattheus was likely to have survived.”

Two weeks before the inquest was due to start, The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust made a full admission that the negligence of its staff caused Mattheus’ death.

Mattheus’ father Vitor Vieira, of Gaywood, King’s Lynn, said:

“Mattheus could find the world a challenging place, but he was a happy child who was dearly loved. He enjoyed school and was very creative. He loved drawing, colouring and painting, and could often be found with his tablet computer in his hand, which provided him with comfort and helped to prevent him from feeling overwhelmed.

“It is hard to put into words the impact Mattheus’ death has had. He deserved the same standard of care as any other little boy but was denied this due to being autistic. We question how it can be that there were signs in the hospital telling staff to be aware of the signs of sepsis, yet Mattheus was overlooked. We want him to now have a voice, and for other autistic patients to be seen and to not needlessly lose their lives.”

Lucy Mellor, a solicitor specialising in medical negligence at law firm JMW who is representing Vitor and Mattheus’ mother Maria Ferreira in a medical negligence case against the hospital trust, said: “This inquest ruling is not only important for Mattheus and his family, but also for autistic patients across the country. Hospitals can be dangerous places for autistic patients and Mattheus’ treatment highlights the shocking inequality that they face. This inequality prevented Mattheus from receiving the basic standard of care he urgently needed. He had a range of sepsis symptoms, but the hospital failed to follow its own screening policy because he didn’t present in the ‘normal’ way. Something has to change to put autistic people on a more equal footing or more lives will be lost.”

Mattheus, who had learning and communication issues, was at times using an iPad during his attendance at the hospital A&E at 10.25pm on April 11, 2022. He had a urinary tract infection and been taken to hospital by his parents, who were concerned about his laboured breathing. Mattheus’ use of an iPad led staff, who had been made aware of his autism, to wrongly believe there couldn’t be anything seriously wrong with him. Despite Mattheus having several symptoms of sepsis, they failed to screen him for this.

Mattheus also struggled to tolerate his observations being taken, with hospital staff recording in his notes that he was ‘uncooperative’, while assuming that abnormal readings were inaccurate. These included abnormally fast breathing, a very fast heart rate and low levels of oxygen in his blood.

Although Mattheus did not act as a typical poorly child due to his autism, physical signs such being cold to the touch, having blue finger nails and looking pale should have raised concerns.

As a result of all these failings Mattheus was not reviewed by a consultant or given IV antibiotics until 16 hours after his arrival at the hospital when he went into septic shock.

He was taken to theatre at 2.20pm on 12th April so that he could be anaesthetised and transferred to paediatric intensive care at another hospital, however, before any anaesthetic could be given, Mattheus suffered a cardiac arrest. CPR was carried out, but Mattheus could not be resuscitated and tragically died.

Recurrent urinary tract infections had been affecting Mattheus for some time, but this had not been properly investigated due to him being unable to tolerate an ultrasound scan that was attempted without any provision for his autism.

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Kelly Hindle 

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