Alex Shaw

Coroner's concerns

AI summary

Critical patient information was poorly communicated and documented between hospital clinicians during telephone consultations, leading to potentially inappropriate advice and highlighting a lack of clear standards for inter-hospital information exchange.

View full coroner's concerns

[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) There was poor communication of the patient’s clinical condition/observations between the Registrar at the Royal Stoke University Hospital and the Consultant at the Birmingham Children’s Hospital when advice was sought by telephone. There was also poor documentation of the contents of the information that had been provided during that conversation and the timing of when the call was made. The evidence of the Consultant at the Birmingham Children’s Hospital was that her advice would have been different if she had been made aware of the patient’s rising heart rate.

(2) The evidence also revealed that it was a “judgment call” when the clinician felt that a dialogue between clinician’s at a different hospital needed to be documented.

(3) Consideration should be given as to how a patient’s observations are communicated to clinician’s between the University Hospital and the Birmingham Children’s Hospital, the time, content, advice and documentation of the conversations.

Responses

2 respondents

University Hospitals of North Midlands NHS Trust NHS / Health Body

16 Jun 2021 PDF

Action Planned

The paediatric team is developing a 'Paediatric Advice Proforma' on the Trust's electronic Iportal system to aid documentation of conversations between hospitals and an associated Standard Operating Procedure. Royal Stoke has appointed a named Consultant to manage children with metabolic disease. (AI summary)

View full response

Dear Ms Murphy

Inquest Touching the Death of Alex Shaw

Further to your letter dated 7 May 2021, I am pleased to provide the following response to address the concerns that you raised at the inquest touching the death of Alex Shaw.

You raised a number of matters of concern to be addressed by both this Trust and Birmingham Children’s Hospital. Set out below are the actions undertaken by University Hospitals of North Midlands NHS Trust in response to the issues highlighted.

1) There was poor communication of the patient’s clinical condition/observations between the Registrar at the Royal Stoke University Hospital and the Consultant at the Birmingham Children’s Hospital when advice was sought by telephone. There was also poor documentation of the contents of the information that had been provided during that conversation and the timing of when the call was made. The evidence of the Consultant at the Birmingham Children’s Hospital was that her advice would have been different if she had been made aware of the patient’s rising heart rate.

2) The evidence also revealed that it was a “judgment call” when the clinician felt that a dialogue between clinician’s at a different hospital needed to be documented.

3) Consideration should be given as to how a patient’s observations are communicated to clinician’s between the University Hospital and the Birmingham Children’s Hospital, the time, content, advice and documentation of the conversations.

Action Taken As a result of the concerns raised, the following action has been taken:

1) The paediatric team are in the process of developing a facility on the Trust electronic Iportal System which will provide a structured note ‘Paediatric Advice Proforma’ to aid electronic documentation of conversations between hospitals when seeking advice on patient care; this will include prompts for important discussion points and will have mandatory fields for vital signs (such as heart rate, BP etc.) which will ensure that the clinician includes such information in conversation. Matters are currently being developed with the IT team and we hope to have a solution by September 2021.

2) In response to point 2, the paediatric team are also aiming to develop a Standard Operating Procedure (SoP) which will also refer to the need to compete the Paediatric Advice Proforma. This SoP will be relevant to discussions between hospital Trusts and will follow on from the work undertaken as per point 1. It will require clinicians to document all discussions.

3) As discussed in point 1 above, the development of the ‘Paediatric Advice Proforma’ will prompt clinicians to input time of conversation, content of the request, information shared and advice given / received.

In addition to the above direct actions, I am also very pleased to share that Staffordshire Children’s Hospital at Royal Stoke has recently appointed a named Consultant who will be responsible for the management of all children with metabolic disease.

I sincerely hope that the above information provides you with assurance that the University Hospitals of North Midlands NHS Trust has taken the matters arising from the inquest touching upon the death of Alex Shaw seriously.

The Trust strives to provide a high standard of care to all patients and I am grateful to you for raising these concerns on this occasion.

Should you wish to discuss any aspect of this report further, please do not hesitate to contact me.

Birmingham Womens and Childrens NHSFT NHS / Health Body

28 Jun 2021 PDF

Action Planned

The Trust is working to transition to the most recent version of the Norse system, which will include features to document patient observations and communication between clinicians. They will also remind clinicians to keep contemporaneous notes about advice given to district general hospitals. (AI summary)

View full response

Dear Ms Murphy

Re: Alex Louise Shaw; Regulation 28 Report to Prevent Future Deaths

I write in response to your Regulation 28 Report issued to Birmingham Women’s and Children’s NHS Foundation Trust on 7 May 2021, following the inquest into the death of Alex Louise Shaw.

On behalf of the Trust, I would like to reiterate the sincere condolences given by Dr and Dr at the hearing on 2 March 2021.

The matters of concern you raised in your Report are as follows;

“(1) There was poor communication of the patient’s clinical condition/observations between the Registrar at the Royal Stoke University Hospital and the Consultant at the Birmingham Children’s Hospital when advice was sought by telephone. There was also poor documentation of the contents of the information that had been provided during that conversation and the timing of when the call was made. The evidence of the Consultant at the Birmingham Children’s Hospital was that her advice would have been different if she had been made aware of the patient’s rising heart rate. (2) The evidence also revealed that it was a “judgment call” when the clinician felt that a dialogue between clinician’s at a different hospital needed to be documented. (3) Consideration should be given as to how a patient’s observations are communicated to clinician’s between the University Hospital and the Birmingham Children’s Hospital, the time, content, advice and documentation of the conversations.”

We do not currently have a Trust wide process or system for logging discussions with other centres or referrals for advice we may receive from other agencies. We are therefore reliant on our colleagues’ documentation and the transfer of that to the patient record. Chief Medical Officer Executive Team Birmingham Women’s and Children’s NHSFT Steelhouse Lane Birmingham B4 6NH

It is acknowledged that this will result in inconsistencies in practice and as a result, the Trust’s Chief Clinical Information Officer (CCIO) as Associate Chief Medical Officer for IT and Information, together with the Trust’s Chief Technology Officer and Data Protection Officer for the Trust are scoping how the recording of information pertaining to patients who are not on our premises but who need specialist clinical advice can be improved.

Norse

We have a limited deployment of an electronic product called Norse. This facilitates a typed ongoing conversation between a clinician’s at this Trust and at another centre. This system includes some features including an ability for our staff to request baseline information at the start of the conversation and include other clinicians as appropriate in the conversation. At conclusion of the discussion, it is then possible to retain the detail of the dialogue.

I understand from my senior IT colleagues that they are currently working with the supplier of this system to support transition to the most recent version of it to include its additional and most up to date features. The long term plan is to have the Norse system rolled out into a number of clinical services in the trust but as yet there is not a defined timetable for this. The roll out of this system will provide a more rigid requirement in respect of the information to be documented, ensuring that patient’s observations are communicated between clinicians at this Trust and colleague’s from other centres.

PERPH

Clinicians at our Birmingham Children’s site will sometimes use some of the functionality in a system which the Trust already has the use of, PEPRH. This is a handover system and provides a facility to record some advice on an ongoing basis. The use of this system is very limited, and is likely to be superseded by the implementation of the Norse system.

PEPR

PEPR is an electronic record keeping system used within this Trust at the Birmingham Children’s site. All PEPR users have the ability to upload any document against any patient record. This is mostly used for retaining incoming correspondence, however, theoretically a clinician could, on giving advice, write themselves an email – and perhaps copy this to the referring clinician – which could then be (manually) uploaded to PEPR.

We will remind clinicians of the need to keep contemporaneous notes about advice given about advice given to district general hospitals by placing a note in patient’s record.

I hope this letter assures you that the concerns you raised have been acknowledged and that efforts are being made to improve record keeping in respect of professional discussions between BWC staff and other centres.

Report sections

Investigation and inquest

On 02/11/2018 I commenced an investigation into the death of Alex Louise Shaw, aged 12. The investigation concluded at the end of the inquest on 29th April 2021.

The conclusion of the inquest was that death was due to complications of therapy for methylmalonic aciduria.

Circumstances of the death

Alex Shaw had a medical history of Methylmalonic Acidemia and chronic kidney insufficiency. She was under the care of the Birmingham Children's Hospital. On the 19th October 2018, she presented to the Children's Assessment Unit of the Royal Stoke University Hospital, Stoke-on-Trent with a three day history of vomiting. She was found to be dehydrated and suffering from mild metabolic acidosis. She was provisionally diagnosed with gastritis or gastroenteritis and treated for the metabolic acidosis with intravenous fluids. A loading dose of carnitine was not administered.

She was admitted to the children's paediatric ward. The metabolic consultant from the Birmingham Children's Hospital was consulted and in agreement with the management plan and they were contacted throughout her admission. Alex was on regular medications for the management of her condition but they were not immediately written on the drugs charts on the Children's Assessment Unit which resulted in 3 missed doses of oral carnitine and a dose of Allopurinol. This did not contribute to her death.

On Sunday 21st October, her lactate level increased and advice was sought from the metabolic consultant. Her heart rate was stable but she continued to vomit. She commenced intravenous bicarbonate at 4.00pm and Intravenous carnitine at 5.30pm the same day. At 6.00pm her heart rate began to rise. She was placed on a heart rate monitor but the time of this was not noted and the metabolic consultant had not been informed. Blood gases at 10.15pm showed that her acid level had not responded. There was a discrepancy as to the timing, but the metabolic consultant had been informed of the blood gas results between 10.30pm and 11.11pm and told that there was a stable heart rate when it was raised. Advice was given to administer a half correction of bicarbonate infusion, to increase the dose of the intravenous sodium bicarbonate injection from 8mmol to 15mmol four times a day, to repeat blood gas after the bicarbonate correction had finished and to give a fluid bolus if haemodynamically unstable.

After a medical review, Alex was found to be haemodynamically unstable and still vomiting. At 11.00pm, a nasogastric tube was inserted which drained 160ml of greenish coloured aspirate .A fluid bolus was administered at 11.30pm before a CT scan. Before the fluid bolus was given, Alex's chest was examined and found to be clear, and there was no evidence of stress to her heart. Intravenous carnitine was administered at midnight and around the same time; the management plan was discussed with the Intensive Care Consultant who was informed that Alex had been transferred to the High Dependency Unit. Consideration was given for transfer to intensive care unit but it was not considered necessary. A CT scan was completed at 1.00am on Monday 22nd October 2018 which did not find any bowel obstruction. The cause of the bilious vomiting was not identified during the hospital admission. Whilst Alex was breathing faster, there was no evidence that she was suffering from a lack of oxygen at the time of the CT scan. After the CT scan, she was started on a half correction of sodium bicarbonate plus 120% of normal fluid correction.

After 2.30am on Monday 22nd October, her oxygen levels had worsened and following review by the Intensive Care Registrar, supplemental oxygen was delivered by a mask. Elective ventilation was not considered necessary prior to 2.30am on Monday 22nd October. A chest x ray was completed and she was diagnosed with pulmonary oedema. The evidence was not able to determine the cause of the pulmonary oedema. Intravenous fluids were stopped apart from the intravenous bicarbonate and she was treated with intravenous furosemide. A decision was made to intubate when she could not manage with oxygen masks alone. The intensive care consultant and anaesthetist were preparing to intubate but her heart rate dropped. Cardiac pulmonary resuscitation was started at 4.08am and a pulse was regained. She was intubated but her heart immediately stopped. Despite chest compression and emergency medication, it was not possible to re-start her heart. The metabolic consultant was contacted when Alex went into cardiac arrest for the second time. Cardiopulmonary resuscitation was stopped at 4.58 hours on the 22nd October 2018 when Alex passed away. A post mortem examination found that death was not due to metabolic acidosis and that there was fluid overload around the lungs, heart and abdominal cavity. The build-up of fluid in and around the lungs resulted in a failure to breathe and led to death. The cause of the bilious vomiting was not identified at post mortem. The free carnitine on the post mortem dried blood spot was 450 umol/L which was within the normal range.

The cause of death was: 1a) Fluid overload due to complications of therapy for methylmalonic aciduria and dehydration. 1b) - 1c) -
2) Chronic Kidney Failure

Similar PFD reports

Shared signals

Coroner's concerns

Responses

Report sections

Similar PFD reports

Related inquiry recommendations

Report details

Responses identified

Sent to

Source links