Tragic toddler death leads to expedited changes at a Southampton hospital

27 July 2023

A two-day inquest has concluded today at The Coroner’s Court, Winchester, investigating the death of Master Zach Keay.

Zach was a beloved son, brother and grandson and his death has had an immeasurable impact on his family.  

On the 7 December 2021, Zach was admitted to University Hospital Southampton NHS Foundation Trust following a period of feeling generally unwell. Sadly, Zach suddenly and unexpectedly passed away in the early hours of the 8 December 2021. His cause of death was unknown and so a postmortem was conducted, and an inquest was opened. 

An initial investigation by the Trust highlighted missed opportunities to escalate his care and that there was a failure to recognise the severity of his condition. The purpose of the inquest was to establish where, how and when Zach came about his death and the family were keen to gain an understanding of the events that led to this sad outcome. 

Coroner’s conclusion: 

Coroner Mrs Rosamund Rhodes-Kemp found the cause of death to be Bronchopneumonia. She provided a narrative conclusion to the Inquest hearing. Within it, she acknowledged missed opportunities by Southampton NHS Trust to review Zach, and to escalate concerns that his condition was deteriorating. If this had been done, then it may have altered the tragic outcome.  

As a result of the investigation into Zach’s death, the Trust have implemented changes to expedite plans to co-locate their paediatric high dependency unit and paediatric intensive care unit, with this due to come into force on 14 August 2023.

Speaking after the conclusion today, Mr Vince Keay, Zach’s Father stated:

As a family we are relieved that the inquest into Zach's death is now concluded, and we have a defined cause of death. We would like to thank the coroner for taking the time to fully consider and understand the medical and clinical reasons that led to his passing and to provide a narrative conclusion. It has been very difficult to hear that there is a possibility that the outcome may have been different, and he could still be with us, if the care he received on that night had been escalated differently, especially with his medical history, 

It is clear to us from the inquest that the nurses & doctors in the hospital with Zach were concerned about him on the night he passed and gave the best care they could. However, processes, procedures and hierarchy within the hospital, that were not up to the standard seen in other areas of the NHS, made giving the right care more difficult than it should have been and may have contributed to our loss. We find some comfort in the fact that Southampton NHS Trust have acknowledged this by accelerating their plans to co-locate their facilities for the most poorly children in their care, which may prevent other families having to go through this in the future.

The family were represented at inquest by Shoosmiths’ appointed counsel, Caroline Allen from 39 Essex and Natalie Blunden, an Associate (FCILEx) at Shoosmiths.



This information is for educational purposes only and does not constitute legal advice. It is recommended that specific professional advice is sought before acting on any of the information given. © Shoosmiths LLP 2024

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