Samuel Parkin

Coroner's concerns

AI summary

Hospital learning points from a child's death were not formally disseminated, and ultrasound reports gave false reassurance about malrotation due to poor understanding of USS limitations, delaying crucial diagnostic tests.

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1. St George's have noted a number of learning outcomes in the course of their M&M process and the Child Death Analysis Form. Whilst I heard evidence of training and informal discussions amongst colleagues both at St George's and regionally, I consider that action is required to ensure that those learning points are formally considered and disseminated throughout St George's and more widely in the NHS.
2. In the course of the evidence it became clear that the inclusion of a comment in the ultrasound report that the SMA/SMV axis was normal gave false reassurance regarding malrotation. The consultant paediatric radiologist was clear that she was not looking for malrotation on the USS (as it was not listed as a potential diagnosis on the ultrasound request), that USS cannot be used to exclude malrotation and that noting that the axis was normal was simply a comment on the anatomy seen and was not the radiologist providing information relating to whether or not malrotation was present. It is recorded in the notes of the M&M meeting which took place following Sam's death and in the evidence that I heard, that although clinicians understood that USS is not the diagnostic test for malrotation and that malrotation will not be seen on an USS in circa 25% of cases, the recording of the axis being normal gave a false reassurance. St George's has changed their practice of reporting of USS to avoid potential confusion in the future. I consider action is required to ensure proper understanding of the limitations of USS in looking for malrotation, in particular in older children, and to avoid any similar confusion regarding the reporting of USS both in St George's and across the NHS.
3. Following Sam's death, St George's has reduced the "threshold" for requesting of upper GI contrast studies in intermittent abdominal pain and intermittent vomiting. Given the serious nature of the potential risk that malrotation carries (namely of volvulus occurring) I consider action is required across the NHS, following St George's lead, to ensure that the symptoms of and diagnostic tests for malrotation, particularly in older children is understood. Where the learning in St George's is informal, I consider action is required to ensure that formal learning takes place within St George's.
4. St George's has implemented a change in `safety netting' advice for those with what is thought to be benign abdominal conditions from Paediatric ED (using QR codes), from wards and outpatient clinic. Advice is give in writing that "benign abdominal diagnosis" does not exclude conditions requiring urgent surgical/ medical review. This action has been taken for the reasons set out above and action should be taken to ensure the wider NHS considers this learning point.
5. One of the learning actions taken by St George's is that re-referrals to gastroenterology are reviewed by another consultant in order that a fresh assessment/second opinion may occur, followed by an MDT discussion and the option of transferring back to the original consultant. St George's feels this may help increase the detection of atypical/unusual presentation of GI conditions, including a later presentation of malrotation. Action is required so that this learning point is considered across the NHS.
6. The evidence before me suggested that there may have been a miscommunication or misunderstandings between the surgical, paediatric and paediatric gastroenterology teams regarding what had and had not been considered and excluded by each during Sam's admission in 2015. In particular, St George's written answers to Mr and Mrs Parkin's question regarding whether there was miscommunication between the treating clinicians was simply "yes". St George's has therefore implemented an inpatient (written) referral form to the GI service. Action is required by St George's and the wider NHS to consider/implement ways to minimise the possibility of miscommunication between teams/in referrals of all disciplines. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 11 November 2024. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Mr and Mrs Parkin (Sam's parents) St George's University Hospitals NHS Foundation Trust. I have also sent it to NHS Scotland, NHS Wales, Health and Social Care Northern Ireland and Royal College of Paediatrics and Child Health, who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. She may send a copy of this report to any person who she believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 16 September 2024 Signature:

Ellie Oakley Assistant Coroner for Inner West London

Responses

2 respondents

NHS England NHS / Health Body

6 Nov 2024 PDF

Action Planned

NHS England will issue national guidance around the limitations of ultrasound to diagnose malrotation and the provision of second opinions, highlighting the importance of communication between teams and multi-disciplinary discussion. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. (AI summary)

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Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths — Samuel Finlay Parkin who died on 16 September 2022. Thank you for your Report to Prevent Future Deaths (hereafter "Report") dated 16 September 2024 concerning the death of Samuel Finlay Parkin on 16 September
2022. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Samuel's parents and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Samuel's care have been listened to and reflected upon. Your Report raised concerns over the understanding of limitations in using ultrasound to diagnose or rule out malrotation, and the threshold for additional diagnostic tests, particularly in older children. You also raised that there may have been miscommunication between the surgical, paediatric and paediatric gastroenterology teams. My response to the Coroner focuses only on the relevant national policy or programmes that sit within NHS England's remit. NHS England's National Specialty Adviser for Gastroenterology, Hepatology and Nutrition has been consulted on your Report and has contributed to this response. Contemporary data suggests that the sensitivity of ultrasound to detect malrotation is around 95%. Standard practice is considered to be a barium study (a type of x-ray / imaging test to examine the oesophagus and stomach), performed to provide further evidence with regards to the diagnosis, although this is also unable to detect malrotation in all cases. As such, it is crucial to ensure that there is joined up working between gastroenterologists and surgical colleagues to ensure that malrotation is ruled out as a diagnosis, through the use of a laparoscope (a type of keyhole surgery where a small instrument / camera is inserted through the abdomen using small incisions) where clinically indicated. The Royal College of Paediatrics and Child Health have produced guidance and examples of good practice in requesting a second opinion (https://www.rcpch.ac.uk/resources/external-second-opinions/process) and note that this may take many forms - including routine second opinion through inter-hospital multi-disciplinary teams (MDTs) or national advisory panels, or through individual consultants.

NHS England Specialised Commissioning will soon begin work to update the published national service specification on Paediatric Gastroenterology, Hepatology and Nutrition which outlines standards for specialised paediatric gastroenterology services. The updated service specification will reference the guidance produced on the provision of second opinions and will also ensure that the importance of communication between multi-disciplinary teams, including surgical, paediatric and paediatric gastroenterology teams, is highlighted. This will include the need for multi- disciplinary discussion for all patients where the results of investigations are not as anticipated. Many of the concerns raised in your Report are local to St George's University Hospitals NHS Foundation Trust and their management of Samuel's care, and it is appropriate that they respond to the Coroner on the matters raised. NHS England has been sighted on and has considered the Trust's response. We note and welcome that the Trust have taken a number of learnings and actions from Samuel's care, to include rewriting their local guidance on the management of abdominal pain in children, holding monthly Paediatric Gastroenterology Radiology meetings, and ensuring regular training around the limitations of ultrasound scans in looking for malrotation. We note that they are also leading on a dedicated malrotation session at the British Society of Paediatric Radiology. We refer the Coroner to the Trust for further information. I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Samuel, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action. Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.

St Georges Epsom and St Helier University Hospitals

13 Nov 2024 PDF

Action Taken

St George's has summarised learning from the case and is presenting at governance meetings; met with Epsom & St Helier; leading a malrotation session; and formalised written referrals to paediatric gastroenterology. They also hold a monthly Paediatric Gastroenterology Radiology meeting to improve communication. (AI summary)

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Dear Ms Oakley This letter is the St George's University Hospitals NHS Foundation Trust response to Matters of Concern 1, 2, 3 and 6 in your Regulation 28 Report to Prevent Future Deaths, dated 16th September 2024, following the sad death of Samuel Parkin on 16th September 2022. The other Matters of Concern are directed towards NHS England, and the Trust has shared relevant information with the Patient Safety team at NHS England to support them in their response. As you know, after Samuel's death, the Trust identified a number of learning points through both our local governance processes and the multiagency Child Death Review process. We believe these have strengthened our mitigations against the risk of future deaths. However, having received your Regulation 28 letter, we have taken a fresh look at the measures we have put in place to ensure these learning points are formally incorporated into our processes at St George's and are widely shared across both St George's and our gesh partner site, Epsom and St Helier's University Hospitals NHS Trust. Matter 1: Action is required to ensure that those learning points are formally considered and disseminated throughout St George's and more widely in the NHS. The paediatric and radiology departments at St George's have worked together to summarise all the learning from Samuel's case and are presenting this formally at departmental Clinical Governance meetings in paediatrics, paediatric surgery and radiology. These presentations will be completed by the end of January 2025. We have met with the clinical leads in paediatrics and radiology at Epsom St Helier Trust to discuss this learning and our changes in practice. They presented this to their sonographers and paediatric radiologists at their Radiology Quality meeting on 9th October 2024. 1

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NHS St George's, Epsom and St Helier University Hospitals and Health Group In addition, the paediatric gastroenterology department have submitted a poster for presentation at the British Society for Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) in March 2025, which summarises the key factors for all paediatricians to be aware of regarding the risk of malrotation. Matter 2: Action is required to ensure proper understanding of the limitations of USS in looking for malrotation, in particular in older children, and to avoid any similar confusion regarding the reporting of USS both in St George's and across the NHS. The limitations of the SMA/SMV axis alone as a marker for malrotation, in particular in older children, are part of the shared learning being disseminated locally. This is now a regular topic for departmental training for paediatric radiology registrar level doctors. The change in the paediatric abdominal reporting standard at St George's is formalised in local radiology protocols, with quality assurance through active audit of reports. This will be part of a presentation during a dedicated malrotation session, organised and led by the St George's team, at the British Society of Paediatric Radiology meeting in November 2024. Matter 3: Where the learning in St George's is informal, action is required to ensure that formal learning takes place within St Georqe's. The paediatric surgery department have carried out an audit of all children with malrotation operated on over 1 year of age across 4 surgical centres in South London and Surrey/Sussex to inform broader learning about this rare but important condition. It has been presented at the regional paediatric surgical meeting at King's College Hospital and will be shared more widely via the national meeting of the British Association of Paediatric Surgeons and the annual meeting for the Royal College of Paediatrics and Child Health in 2025. The reduced threshold for considering an upper GI contrast study for intermittent abdominal pain and vomiting is one of our key learning points, while remaining mindful of the need to avoid excess exposure to radiation and limit iatrogenic harms. Informed by our audit, we recognise the cohort of patients to be most aware of - older children, with episodic or intermittent vomiting associated with abdominal pain. We have rewritten our local guidance on management of abdominal pain in children to include awareness of this situation and ensure the correct imaging is requested. The guidance is currently being ratified through local governance processes. The new guideline will be reinforced through regular departmental teaching. Matter 6: Action is required by St Georqe's and the wider NHS to consider/implement ways to minimise the possibility of miscommunication between teams/in referrals of all disciplines. We recognise that communication between teams is vital in good patient care, and we fell short of this. 2

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NHS St George's, Epsom and St Helier University Hospitals and Health Group The requirement for thorough, contemporaneous documentation and communication between teams is reinforced in our local resident doctor induction and training. We have now formalised written referrals to paediatric gastroenterology in the patient record and will be rolling this out for all specialty consult requests within the paediatric directorate, with the expectation that a clear referral outcome will be formally documented. In addition, we now hold a monthly Paediatric Gastroenterology Radiology meeting where complex cases are discussed. This is attended by consultant and resident doctors from paediatric gastroenterology, paediatric surgery and radiology and the outcomes of this meeting are recorded in the electronic patient record. This is leading to improved communication between paediatrics and radiology and allows diagnostic uncertainty to be openly discussed. I hope this response provides you, and Samuel's family, with assurance that the Trust have taken this matter extremely seriously and that we are committed to putting these improvements in place and sharing our learning with colleagues across the NHS.

Report sections

Investigation and inquest

On 9 October 2022 the Senior Coroner commenced an investigation into the death of Samuel Finlay Parkin. The investigation concluded at the end of the inquest on 6 September 2024. The conclusion of the inquest was: Samuel Finlay Parkin died from hypoxic brain injury following a cardiac arrest caused by midgut volvulus which occurred due to an undiagnosed malrotation which had been present from birth. The treating clinicians' analysis of Sam's symptoms and false reassurance from the result of an ultrasound meant further tests which could have diagnosed malrotation were not carried out, leading to a misdiagnosis. The undiagnosed malrotation was therefore not surgically treated. The malrotation caused the volvulus to occur. Had the malrotation been operated on it is likely that the death would not have occurred.

Circumstances of the death

Sam died on 16 September 2022 from hypoxic brain injuring following an out of hospital cardiac arrest on the night of 13-14 September, caused by midgut volvulus. The volvulus occurred due to Sam having an undiagnosed malrotation, which had been present since his birth. Sam was seen on multiple occasions at St George's hospital over the course of his life — in the Emergency Department in 2013, 2015 and 2016 and as an outpatient in 2016 and 2022. The only time malrotation was listed within the notes as a potential diagnosis was in the ward round notes from his admission in 2015. An ultrasound was done in 2015 but not an upper GI contrast, or Barium, study. The ultrasound request (in 2015) from the surgical team did not mention malrotation as a possible diagnosis. The ultrasound report noted that the SMA/SMV axis was normal, but did not comment specifically on malrotation. The evidence of the Radiologist, Paediatric Gastroenterologist and expert witness (a Consultant Paediatric and Neonatal Surgeon) was clear that ultrasound cannot exclude malrotation. The clinicians who treated Sam gave evidence that their level of suspicion for malrotation was low. Sam was misdiagnosed. Having considered the evidence, including the opinion of the expert witness, I found that the repeated nature of Sam's symptoms (in particular, vomiting which was sometimes green and severe abdominal pain) over a number of years meant that an upper GI contrast study should have been carried out to look for malrotation. As is set out in the conclusion, had that test been conducted it is likely that it or further tests (if the barium study had been equivocal) would have identified the malrotation and it would have been treated through surgery, thereby significantly reducing the risk of volvulus and Sam's ultimate death. The evidence also showed that Sam's parents were not given sufficient safety netting advice which meant that, due to the misdiagnosis and the information/reassurance that they had received over a number of years of bringing Sam to hospital, they did not bring Sam into hospital earlier when he was, unbeknown to them, suffering from the volvulus that proved to be fatal. The medical cause of death on the Medical Certificate of Cause of Death was: 1a Hypoxic Ischaemic Encephalopathy 1 b Cardiac Arrest 1c Midgut Volvulus

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