Overview

• At Kent and Medway Coroner’s Court, Shanice Kneebone said clinicians did not take her escalating concerns seriously during Tommy’s final admission.
• The seven-month-old had been seen repeatedly by GP and A&E services in the months before his death without the underlying cardiomyopathy being identified.
• Attempts to start an IV were delayed, including a nurse saying she lacked experience and others struggling to find a vein.
• Staff discussed inducing a coma for transfer to Evelina Children’s Hospital as Tommy deteriorated, while his family later learned CPR was performed for more than an hour.
• He was pronounced dead after 4am on 21 January 2023, doctors recorded an undiagnosed cardiomyopathy as the cause, and subsequent parental tests found no genetic cardiac issue.