Thea Wilson, instructed by Jenny Hawkes of Thomson Snell & Passmore acted on behalf of the family of Tommy Kneebone who died on 21 January 2023 after what the Coroner described as a “cascade of missed opportunities to provide appropriate care to Tommy”. Area Coroner Sarah Clarke held that each of those missed opportunities “added fuel to the next with devastating effect on the clinical input received by Tommy”.
The inquest heard from 18 witnesses over six days at a hearing at Maidstone Coroners Court in September 2025.
The Coroner found that Tommy exhibited clear red-flag signs of clinical deterioration on the 19th and 20th January 2023. Despite this, his fluid intake and output were not monitored; his PEWS scoring was incomplete and not properly interpreted; his observations were infrequent despite abnormal readings, and parental concerns were repeatedly raised but not acted on. The Coroner held that this was more than a mere lapse in judgment and amounted to failure to provide basic medical attention to a dependent child showing signs of deterioration. Had simple measures of appropriate monitoring, fluid management, senior review, and timely escalation been undertaken, Tommy would likely have received earlier supportive care. Whilst his underlying condition of cardiomyopathy might not have been preventable, these failures materially contributed to Tommy’s death.
The inquest returned a conclusion of Natural Causes – Contributed to neglect.
The BBC news coverage can be read here.
