Neglect Contributed to Death of Three-Year-Old Oscar Neillings, Inquest Concludes

The family of a young boy who died from sepsis are calling on Chesterfield Royal Hospital NHS Foundation Trust to publish a detailed action plan to be made public, proving that lessons have been learned and meaningful changes made to prevent further harm.

The call to action follows the conclusion of a three-week inquest into the death of three-year-old Oscar Bert Neillings, who died on 8 November 2023, following which the jury determined that he died from natural causes contributed to by neglect.

Described by his family as joyful, confident, and full of life, a jury at Chesterfield Coroner’s Court heard that Oscar had been seen by two out-of-hours GPs in the days before he was admitted to Chesterfield Royal Hospital.

He was transferred by ambulance after another GP visit but later suffered a cardiac arrest and died that evening.

The inquest, which concluded on Friday, 23^rd of May, examined missed opportunities to diagnose and treat sepsis, as well as broader concerns about how the Trust manages paediatric emergencies.

On the day he died, Oscar arrived at hospital at around 10.30am but was not given antibiotics until 12.54pm. He died at 5.30pm. His cause of death was recorded as sepsis (1A), resulting from bronchopneumonia and invasive Group A streptococcal infection.

Medical experts told the hearing that Oscar’s care was fragmented and lacked urgency, and that national sepsis protocols—including early fluid resuscitation, timely antibiotics, and critical care escalation—were not followed.

While the Trust acknowledged during the inquest that it has learned lessons and implemented changes – and has confirmed the existence of an action plan – Oscar’s parents, Mark and Stephanie Neillings, are calling for that plan to be made public.

They insist that only full transparency will ensure genuine accountability and help restore trust in the care provided to children and families.

Oscar’s mum, Stephanie Neillings, 33, from Walton, Chesterfield. said: “I knew he wasn’t well, but I was dismissed and his care felt completely chaotic and inconsistent. I wondered “could this be sepsis” but didn’t verbalise that. I thought I was going mad. For medical professionals not to recognise it – it’s something I’ll never understand.

“Nothing will bring back our son, our other children’s brother, but we are determined that by telling Oscar’s story, speaking out and making sure the Trust delivers on its promise of change, we hope no other family has to suffer like we have.”

Helen Reynolds, medical negligence lawyer at Fletchers Solicitors – who supported the family during the inquest and is now representing them in a civil claim against the Trust – said: “This inquest has brought painful clarity to what went so tragically wrong in Oscar’s case. The failings in his care are deeply distressing. But the family’s courage in sharing their story must lead to action.

“I have the utmost respect for the strength, dignity, and resilience Mark and Stephanie have shown throughout what has been an incredibly difficult and emotional three weeks. Their determination to ensure no other family suffers as they have is both inspiring and humbling.

“The Trust says it has produced an action plan, but it has not been made public. We fully support the family’s call for a detailed, published plan that is open to scrutiny.

“Any changes must be accompanied by clear deadlines, measurable outcomes, and complete transparency. Families deserve assurance that these commitments are being honoured—and that no other child will be failed in the same way.”

In a tribute, Stephanie remembered Oscar as “an early riser, full of energy and love for life”. She said he adored playing with his siblings, talking to neighbours, watching bin lorries, and scooting at full speed down the street.

She recalled: “He’d shout ‘FIRE FIRE’ from under his bed while playing with fire trucks, sing ‘Twinkle Twinkle’ at 4am, and demand an ice cream before dinner.

“He chased his brother Maxwell in circles and looked out for his little sister Poppy. Life was chaotic—but so, so full of joy. I was always frazzled, but so grateful. The house is so quiet now. What I’d give to hear those screams and laughter again.”

Stephanie concluded: “Oscar was seen by numerous doctors. Some acknowledged the possibility of sepsis, yet it still wasn’t treated. That failure is devastating.

“It shouldn’t be this way. The public needs to know what to look for—the signs and symptoms of sepsis—and to feel empowered to ask, ‘Could this be sepsis?’ Use the word. Speak it out loud. It can save lives.

“I remember being asked about Oscar’s urine output and sepsis crossed my mind, but I didn’t say anything. That haunts me every day. I didn’t want to appear as though I was questioning a consultant. But I wish I had. Sepsis is so common—five people die from it every hour in the UK.

It must be treated with the urgency we give to heart attacks or strokes. Oscar was amazing. He deserved better. This inquest must lead to meaningful change—not just in Derbyshire, but across the NHS. Every child deserves the chance Oscar didn’t get.”

Oscar’s family was represented at the inquest by Sefton Kwasnik, Director of Ozon Solicitors Ltd, who added: “This has been a harrowing and traumatic case which should never have happened. If the majority of the hospital staff had been aware of and followed their own protocols for dealing with sepsis in young children.”

Dr Ron Daniels, Founder and Chief Medical Advisor, the UK Sepsis Trust, said: “Every day at the UK Sepsis Trust (UKST) we hear stories just like Oscar’s: about the terrible consequences of failing to spot and treat the key signs of sepsis swiftly. Surviving sepsis – particularly for children but for people of all ages – should not come down to advocacy or a postcode lottery.

“UKST’s mission is to end preventable deaths from sepsis. We know that by responding quickly and effectively we can save lives and improve outcomes for the thousands of people affected by this condition every year. We need improved public awareness of sepsis, and a commitment from health ministers on the development and implementation of a uniform and resourced ‘sepsis pathway’ – a standardised treatment plan that ensures patients receive the right care from the point at which they present their symptoms to a clinician through to receiving their diagnosis.”