Inquest into the death of Shaun BELL

4y · Male·Peritoneal sepsis caused by a perforated duodenal ulcer

A 4-year-old boy with significant global developmental delay and non-verbal communication died from peritoneal sepsis caused by a perforated duodenal ulcer. Presentation included lethargy, poor oral intake, low haemoglobin (61 g/L), very low sodium (114 mmol/L), elevated white cell count, and persistent tachycardia. Critical clinical lessons: (1) multiple clinicians failed to appreciate how critically unwell he was, resulting in failure to escalate care urgently; (2) a junior registrar inappropriately altered SPOC calling criteria without consultant discussion; (3) a provisional viral gastroenteritis diagnosis was inadequately reconsidered despite accumulating abnormal pathology; (4) the daytime team did not perform fresh assessment of the clinical picture but were influenced by preceding teams' reassurance; (5) tele-triage nurses lacked specific training in assessing non-verbal developmentally delayed children for serious pathology. A collective 'group think' failure meant the combination of findings that should have triggered immediate escalation and higher-level investigation was missed.