Medway Maritime Hospital
NHS / Health Body
Action Taken
Medway Maritime Hospital updated its paediatric guidelines (version 6.8) and uploaded them to QPulse in March 2021. The updated guidelines include factors that doctors need to be aware of in clinical presentation, assessment requirements, and monitoring levels. (AI summary)
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Dear Ms Hayes,
Prevention of Future Deaths Regulation 28 Report – Luke Jackson
We refer to your report issued following the inquest touching upon the death of Luke Jackson dated 24 February 2021 pursuant to Regulation 28 of the Coroner’s (Investigations) Regulations 2013.
(1) Luke had complex needs and was awaiting results of genetic testing relating to Becker’s Muscular Dystrophy. He had not been eating and drinking and had loose stools and vomiting that had progressed over a five-day period on a background of a chest infection. His parents had sought and followed medical advice from the hospital by telephone. Luke continued to deteriorate, and he was admitted. The Trust took some steps on admission to address his low potassium.
(2) Evidence was heard from a Consultant from the Evelina Children’s Hospital that many children among their 2000 referrals each year have diarrhoea and vomiting as a first symptom. Metabolic derangement in a child with myopathy may be associated with total body potassium depletion: children with myopathies have a low muscle mass that compromises their ability to correct their own potassium levels when unwell. This is often not well recognised by treating clinicians. Treatment for this condition may need to be undertaken in intensive care due to the increased amounts of potassium required to correct the derangement and manage clinical risks.
(3) Luke had a chest infection, however his low potassium made him weaker and as it progressed, he was shunting blood away from his gut to compensate (this assists to protect vital organs such as the heart and brain) which resulted in loose stools and vomiting that were not a consequence of gastroenteritis. One of the early symptoms of this shunting process is a high heart rate. In addition, development of a chest infection requires a child to breath harder and this is Medway Maritime Hospital Windmill Road Gillingham Kent ME7 5NY
more difficult in a child with myopathies who is already weakened due to low potassium and who may as a result not present with the usual symptoms of respiratory distress.
The following is our response in relation to the matters of concerns raised:
The Trust has updated their Paediatric Guidelines (GUDPCM016) in response to patients with myopathies to reflect that:
• All doctors must be aware that… o These patients are likely to have a low muscle mass and that a low serum potassium may indicate underlying deficit in total body potassium o Chest infection can lead to blood redistribution from the gut (leading to diarrhoea and vomiting) and so mimic gastroenteritis o Respiratory compromise may not show by typical symptoms and signs.
• These patients must be fully assessed by a Registrar or above (in common with oncology patients) before discharge.
• These patients must have a low threshold for admission to HDU with full cardiac monitoring, saturation monitoring and potassium replacement. All children admitted to HDU are now discussed with the South Thames Retrieval Service (STRS) as a matter of course.
The Trust has also updated their Paediatric Guidelines with regards to the indications for contacting the STRS in children with hypokalemia and contacting STRS. Our STRS link, Dr who has agreed that STRS do not expect to be contacted for all children with a serum K < 3.0. The use of dilute peripheral solution for potassium remains safe and first line option in District General Hospital settings in appropriately chosen patients.
Prevention of Future Deaths Regulation 28 Report – Luke Jackson
We refer to your report issued following the inquest touching upon the death of Luke Jackson dated 24 February 2021 pursuant to Regulation 28 of the Coroner’s (Investigations) Regulations 2013.
(1) Luke had complex needs and was awaiting results of genetic testing relating to Becker’s Muscular Dystrophy. He had not been eating and drinking and had loose stools and vomiting that had progressed over a five-day period on a background of a chest infection. His parents had sought and followed medical advice from the hospital by telephone. Luke continued to deteriorate, and he was admitted. The Trust took some steps on admission to address his low potassium.
(2) Evidence was heard from a Consultant from the Evelina Children’s Hospital that many children among their 2000 referrals each year have diarrhoea and vomiting as a first symptom. Metabolic derangement in a child with myopathy may be associated with total body potassium depletion: children with myopathies have a low muscle mass that compromises their ability to correct their own potassium levels when unwell. This is often not well recognised by treating clinicians. Treatment for this condition may need to be undertaken in intensive care due to the increased amounts of potassium required to correct the derangement and manage clinical risks.
(3) Luke had a chest infection, however his low potassium made him weaker and as it progressed, he was shunting blood away from his gut to compensate (this assists to protect vital organs such as the heart and brain) which resulted in loose stools and vomiting that were not a consequence of gastroenteritis. One of the early symptoms of this shunting process is a high heart rate. In addition, development of a chest infection requires a child to breath harder and this is Medway Maritime Hospital Windmill Road Gillingham Kent ME7 5NY
more difficult in a child with myopathies who is already weakened due to low potassium and who may as a result not present with the usual symptoms of respiratory distress.
The following is our response in relation to the matters of concerns raised:
The Trust has updated their Paediatric Guidelines (GUDPCM016) in response to patients with myopathies to reflect that:
• All doctors must be aware that… o These patients are likely to have a low muscle mass and that a low serum potassium may indicate underlying deficit in total body potassium o Chest infection can lead to blood redistribution from the gut (leading to diarrhoea and vomiting) and so mimic gastroenteritis o Respiratory compromise may not show by typical symptoms and signs.
• These patients must be fully assessed by a Registrar or above (in common with oncology patients) before discharge.
• These patients must have a low threshold for admission to HDU with full cardiac monitoring, saturation monitoring and potassium replacement. All children admitted to HDU are now discussed with the South Thames Retrieval Service (STRS) as a matter of course.
The Trust has also updated their Paediatric Guidelines with regards to the indications for contacting the STRS in children with hypokalemia and contacting STRS. Our STRS link, Dr who has agreed that STRS do not expect to be contacted for all children with a serum K < 3.0. The use of dilute peripheral solution for potassium remains safe and first line option in District General Hospital settings in appropriately chosen patients.