Kellum Thomas

On the 11th June 2021, I commenced an investigation into the death of Kellum Paul Thomas aged thirteen years. The investigation concluded at the end of the inquest on the 8th July 2022. The conclusion of the inquest was Natural Causes.

Kellum collapsed at his home address around 20.00 hours on the 9th June 2021. He had a cardiac arrest from which he could not be resuscitated, and was pronounced deceased at Queens Medical Centre, at 21.37 hours on that day. He had a REVEAL device in situ, to monitor his heart rate and rhythm, which showed that he developed Ventricular Tachycardia (VT), deteriorating into Ventricular Fibrillation (VF) leading to his death. The REVEAL device had been in place from 2016 (when he very likely had a previous cardiac arrest), although the battery in this device had stopped functioning likely in September 2019. The device was not replaced until February 2021. Whilst there had been no previous documented episodes of VT or VF, only clusters of extra ventricular beats, there was a missing period of recording of heart rate and rhythm between Sept 19 and February 2021. There was no clear indication for treatment with an implantable Defibrillator based on his presentation and REVEAL device recordings, although this decision had been considered carefully. There was a working diagnosis of a rhythm disorder of the heart known as Catecholaminergic Polymorphic Ventricular Tachycardia, although this was not proven in life, though now thought likely to be the cause of his death based on the final rhythm change and the normal structure of the heart confirmed at Post Mortem examination. Kellum was seen in March 2021 by his Cardiologist, and was well. The planned increase in Atenolol was not implemented following this appointment, as the letter to the GP to initiate the change did not reach the GP until after Kellum's death. Whilst there were issues of care in this case, I cannot say they have caused or made a significant contribution to his death on a balance of probability, as the fatal rhythm change had not been demonstrated previously, and Kellum had had no ongoing symptoms to suggest he was at risk of a fatal arrhythmia.