Family of one-year-old Balderton baby will never know why he died as Nottingham coroner says death is unexplained

A family will never know why their one-year-old baby died after a coroner recorded his death as unexplained.

An inquest into the death of Kenny-John Elijah Beckett-Ward, who was found unresponsive by his mother, Chantelle Beckett, at their home in Balderton on March 7, 2024, concluded today (Friday, February 21).

The assistant coroner Dr Elizabeth Didcock described Kenny, who had been in and out of hospital since his premature birth, as ‘very vulnerable’.

She said in a narrative verdict that there were several risk factors that could have led to his death but nothing could be established, ‘despite a broad and full investigation’ that directly caused it.

Dr Didcock recorded his death as unascertained, following the post-mortem examination, and said his death “remains unexplained”.

The social care staff involved with Kenny prior to his death had carried out a rapid review, and Dr Didcock said the learnings from this review would “likely improve all agency staff working practices, with a family where there is longstanding neglect” and “reduce the risk of future deaths occurring in similar circumstances”.

The inquest started on Wednesday (February 19) and heard from a range of witnesses including medical staff, social workers and Nottinghamshire police officers.

Kenny was born prematurely at 27 weeks at Lincoln County Hospital on December 24, which led to chronic lung disease.

Days after his birth, Kenny was transferred to the neonatal unit at the Queen’s Medical Centre in Nottingham and was discharged on March 30. He continued doing oxygen therapy at home until August 23, 2023.

On the day prior to his death (March 6), Kenny was put to bed around 7pm by his dad Stefan Ward and he kissed him again at around 10pm the same evening.

At about 3am, Kenny’s mother fed him and went back to sleep.

On March 7, the inquest heard that Chantelle heard Kenny make a noise at around 8am, which she said was normal considering he snored.

Chantelle left to take Kenny’s two siblings to nursery and school before returning at around 9am, when she went to check on him and found him unresponsive.

The parents performed CPR and called the emergency service who declared Kenny deceased at 9.28am.

The post-mortem examination by Michael Biggs, the registered forensic pathologist at Leicester Royal Infirmary, revealed Kenny’s medical cause of death to be unascertained.

Throughout the inquest, it was heard that at the time of Kenny’s death, the family’s home had dirty nappies all over, faeces on the floor, dirty pots and food waste, and a fly infestation in the kitchen.

Dr Didcock in her conclusion noted that, together with his lung disease, his growth pattern and weigh loss was “concerning” and “due to a lack of necessary nutrition”.

“The home conditions in which Kenny lived, including where he slept were very unhygienic, and he was under nourished,” she added.

“He was prone to viral respiratory infection. Both parents smoked. All these factors increased the risk of him dying suddenly and unexpectedly, although none of them are directly causal.”

From May 23, 2024, Kenny was on a child protection plan under the category of neglect, previously on a child in need plan.

In April 2023 he was very unwell with bronchiolitis, requiring two admissions, the first following an apnoeic episode at home, necessitating a Paediatric Intensive Care Unit admission to Queens Medical Centre, Nottingham.

The inquest heard that on both occasions there was concern that Chantelle did not appreciate how unwell he was, and the urgency of admission.

The inquest heard that the family missed numerous medical appointments in the months up to Kenny’s death, despite social services’ attempts to ensure they had the funds and ability to attend them and discuss this with them in meetings — while the coroner noted medical professionals had become increasingly concerned about the non-attendance of appointments.

From July 2023 until Kenny’s death, the family missed 21 appointments doctor appointments, including 11 since January 2024, which were cancelled or the family failed to attend or walked out.

Dr Didcock added: “There may have been an opportunity to achieve a hospital admission at the end of February 24, when he was coughing and chesty, and very underweight, but I cannot say that even if this had been achieved, it would have prevented his death, which was sudden and remains unexplained.”

From early January 2024, until Kenny’s death there were increasing concerns raised by the paediatric consultant and the health visitor about Kenny’s breathing issues, the lack of attendance at arranged appointments, his growth faltering and his developmental delay.

Kenny had a delayed development, meaning he would make limited sounds, would not crawl, walk and wasn’t rolling well.

She concluded by giving her sincere condolences to the father Stefan Ward, the mother Chantelle Beckett, the sisters and the extended family.

The coroner recommended Kenny’s family go through the report with a paediatrician to consider whether or not “further cardiac genetic investigations” may provide an answer in understanding what happened to Kenny.

She also passed on her condolences to Kenny’s parents, siblings and the wider family.