An 11-year-old autistic schoolboy was branded “uncooperative and difficult” by medics who missed "multiple red flags" to diagnose sepsis causing fatal delays in the hours before his death. 

Mattheus Ferreira-Vieira, who was non-verbal, was taken to the Queen Elizabeth Hospital (QEH) with a kidney infection on April 11, 2022.

He struggled to cope with medical staff taking observations, and sections of his notes described him as "uncooperative and difficult.” 

He died the following day on April 12 following a cardiac arrest. 

Eastern Daily Press: Mattheus Ferreira-Vieira with his parents Vitor Vieira and Maria Ferreira

An inquest into his death took place at Norfolk Coroner’s Court, based at County Hall in Norwich, on February 27. 



In a statement to the court, his father, Vitor Vieira, a machine operative at the QEH, said: “For the avoidance of any doubt, neither Maria [Mattheus’s mother] nor I were told that Mattheus might have sepsis prior to his death. 

“As non-medical professionals, Maria and I trusted the doctors to accurately diagnose Mattheus and tell us what was wrong.” 

Mr Vieira described the heart-breaking moments before his son went into cardiac arrest. 

"All of a sudden, he was wheeled out of the room on the hospital bed and rushed down the corridor to an operating theatre,” he added.

“The people pushing his bed were shouting at others in the corridor asking them to ‘get out of the way’. 

"I entered the operating theatre with Mattheus before being told I had to leave. 

“A nurse told me Mattheus’s heart had stopped beating. 

“The doctor told us that they had stopped trying to resuscitate Mattheus and that he had died.” 

Eastern Daily Press: Mattheus Ferreira-Vieira


Evidence read out heard that there had been “multiple red flags” to diagnose sepsis and that a 'paediatric sepsis pathway' should have been triggered, as well as a review by a senior doctor.   

But several observations were dismissed as "inaccurate" by some medical staff who believed Mattheus’s behaviour to be the route cause of abnormal test results. 

In fact, the observations were accurate and indicated that his kidney infection had developed into septic shock. 

In a letter seen by the EDP, the King's Lynn NHS Foundation Trust wrote to the family. 

It said: "It is admitted by the Trust that there were failings in the delivery of the care that was provided to Mattheus following his admission on 11.04.22. 

"In particular, it is admitted that there was a delay in diagnosing life-threatening sepsis and that there was a subsequent failure to adequately manage sepsis. 

"It is further admitted that, on the balance of probabilities, Mattheus would not have died but for those failings in his care. 

"It is accepted it is likely that, with adequate resuscitation, Mattheus would have made a full recovery." 

Eastern Daily Press: Mattheus Ferreira-Vieira


Speaking after the inquest, Mr Vieira said: “Mattheus could find the world a challenging place, but he was a happy child who was dearly loved.

“He enjoyed school and was very creative. He loved drawing, colouring and painting, and could often be found with his tablet computer in his hand, which provided him with comfort and helped to prevent him from feeling overwhelmed.  

“It is hard to put into words the impact Mattheus’ death has had.   

“He deserved the same standard of care as any other little boy but was denied this due to being autistic.   

“We question how it can be that there were signs in the hospital telling staff to be aware of the signs of sepsis, yet Mattheus was overlooked.   

“We want him to now have a voice, and for other autistic patients to be seen and to not needlessly lose their lives.” 


Lucy Mellor, a solicitor at law firm JMW who is representing Mattheus’s parents, added: “This inquest ruling was not only important for Mattheus and his family, but also for autistic patients across the country.   

“Hospitals can be dangerous places for autistic patients and Mattheus’ treatment highlights the shocking inequality that they face.   

“This inequality prevented Mattheus from receiving the basic standard of care he urgently needed.   

“He had a range of sepsis symptoms, but the hospital failed to follow its own screening policy because he didn’t present in the ‘normal’ way.   

“Something has to change to put autistic people on a more equal footing or more lives will be lost.”  

The primary medical cause of death was given as septicaemia (E. coli). 

Area coroner, Yvonne Blake, recorded a narrative conclusion.  

She said: “Mattheus died from sepsis which was not recognised in a timely fashion and the appropriate treatment not instigated. His death was contributed to by neglect."