A grieving mother has shared her agony after her 12-year-old son died from kidney disease following a seven-hour delay in medics giving him fluids.
Brandon Dables, 12, died in April 2021 after being admitted to the children's emergency department at Royal Derby Hospital with symptoms such as vomiting and difficulty seeing.
The child, from Ripley, East Midlands, had a reduced kidney function and a history of water infections.
He underwent tests that indicated he may have a kidney injury. Around four hours after he was admitted doctors said he should start intravenous antibiotics and fluids. But these were not administered until the early hours of the next morning.
Brandon, who had a number of disabilities including a chromosome disorder and ADHD, suffered a cardiac arrest around three hours after he started to receive fluids. He died the same morning in hospital.
After his death Marilyn Wright, Brandon's mother, instructed specialist medical negligence lawyers at Irwin Mitchell to investigate his care and support her through an inquest.
She said: 'When I was told that Brandon had passed I couldn't quite believe it. Even two years on trying to come to terms with what happened remains incredibly difficult.
'Brandon was non-verbal but people who knew him well could understand his needs. Despite all of his medical diagnoses, Brandon was such a happy and loving little boy.
'He was always smiling and giggling and had a cheeky side to him. He was a Derby County fan and enjoyed watching and playing football with his brothers.
'In the weeks prior to his hospital attendance, Brandon was well in himself. However, the weekend before he started to feel unwell.
'He started vomiting over the weekend, refusing fluids and wasn't himself so knew I had to take him to hospital. He was a popular and much-loved student at Alfreton Park Community special school.
'I kept asking the nurses when Brandon would be given his fluids and antibiotics but they kept saying that they were waiting for a doctor to do that. It just felt like it was taking a long time.
'I could see Brandon was getting worse and I was anxious and worried. It felt strange that they didn't put him on fluids straight away as when he has attended previously that was the first thing they did.'
Brandon arrived at Royal Derby Hospital on April 26 at 2.45pm. He started antibiotics at around 12.10am on April 27 and intravenous fluids at around 1am. Just before 4.30am that same day, Brandon suffered a cardiac arrest.
Medics tried to resuscitate him but he was pronounced dead at around 7.10am.
His Mother Marilyn said: 'Brandon faced many challenges but with his happy outlook and determination, he taught people he met how to be a better person.
'I'm still in trauma about the way Brandon died but needed to be his voice to at least establish the answers he deserved regarding his care and what happened to him.
'I can't put into words the distress of losing my child. It's difficult not to think when Brandon needed help the most he was badly let down. I feel they didn't take into account his additional needs, and the concerns I had as his mum. I knew him far better than anyone but feel like my concerns weren't taken seriously.
'I'd do anything to have Brandon back in our lives but know that's not possible. All I can hope for now is that no one else has to go through what our family continues to go through each and every day.'
A Patient Safety Incident Investigation report by the Hospital Trust identified 'several significant' failures. These included a failure by doctors to communicate to nurses the 'urgency' of getting fluids into Brandon's body and a failure by nurses to prioritise this.
The failure to deliver intravenous fluids 'in a timely manner' was 'an unacceptable delay in clinical care,' the report found. Ahead of an inquest and around eight months after the report was finalised, the Hospital Trust admitted liability for Brandon's death following legal submissions by Irwin Mitchell.
An inquest has concluded Brandon probably would not have died had he been given intravenous fluids to treat his kidney infection 'within a reasonable timeframe'.
Tania Harrison, the expert medical negligence lawyer at Irwin Mitchell, representing Marilyn, said after the hearing: 'The hurt and pain that Brandon's family feel following their loss is as raw now as it was when he died.
'Throughout that time Marilyn has been left trying to come to terms with Brandon's death while at the same time having many concerns about the care he received. Sadly Marilyn's concerns have been validated with investigations identifying serious failings in Brandon's care which ended with devastating consequences.
'While nothing can make up for what Brandon's family are going through, it's now vital that lessons are learned from what happened to him to improve patient safety for others.'
The investigation also concluded that after he died, communication with Brandon's family in hospital and in the weeks and months after was 'unsatisfactory'.
An inquest at Derbyshire Coroner's Court found Brandon died from a kidney disease caused by intermittent catheterisation and recurring water infections. Coroner Peter Nieto recorded a narrative conclusion.
Brandon's mother Marilyn also wants bosses at University Hospitals of Derby and Burton NHS Foundation Trust to improve how it treats families following the death of a loved one after an NHS investigation report revealed communication with her following her son's death was 'unsatisfactory'.
Dr Sree Andole, Interim Medical Director at UHDB, said: 'Our heartfelt condolences remain with Brandon's family, and we are very sorry that aspects of the care we provided to him did not meet the level he or his family needed from us.
'We have taken Brandon's case seriously and acted on our learning to put changes in place, including building a new alert into patient monitoring systems to help respond to changes more quickly, enhanced training for staff to support better communication between teams, and introducing pre-filled syringes for certain medicines so that they can be administered quicker.
'We are grateful to Ms Wright for her strength in sharing her feedback on how we can improve our engagement with families, and we have since proactively invested in specialist bereavement nurses so that we can provide better and dedicated support to families at these incredibly difficult times.'
Dr Sree Andole, Interim Medical Director at UHDB, told MailOnline: 'Our heartfelt condolences remain with Brandon's family, and we are very sorry that aspects of the care we provided to him did not meet the level he or his family needed from us.
'We have taken Brandon's case seriously and acted on our learning to put changes in place, including building a new alert into patient monitoring systems to help respond to changes more quickly, enhanced training for staff to support better communication between teams, and introducing pre-filled syringes for certain medicines so that they can be administered quicker.
'We are grateful to Ms Wright for her strength in sharing her feedback on how we can improve our engagement with families, and we have since proactively invested in specialist bereavement nurses so that we can provide better and dedicated support to families at these incredibly difficult times.'