Source · Prevention of Future Deaths

Edward Joyce

Ref: 2018-0142 Date: 9 May 2018 Coroner: Philip Barlow Area: London Inner (South) 1 response identified · 2 indexed addressees View PDF

AI-generated concerns summaryA high temperature in a young child following a burn did not trigger an urgent hospital referral or subsequent recording by a hospital nurse when reported, resulting in no advice for parents. The coroner suggests reviewing information for other health professionals.

Date 9 May 2018

56-day deadline 6 Jul 2018 stated in the report

Responses identified 1 of 2

Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

A high temperature in a young child following a burn did not trigger an urgent hospital referral or subsequent recording by a hospital nurse when reported, resulting in no advice for parents. The coroner suggests reviewing information for other health professionals.

View full coroner's concerns

May The they him the

: _ The evidence at the inquest was that a temperature reading above 38'C following a burn to a young child is highly concerning; and could be an early sign of septicaemia and toxic shock syndrome (1) The temperature reading of 38.9'C at the GP did not trigger an urgent referral to hospital.

(2) Eddie's mother was clear that she reported this temperature reading to the nurse at Chelsea & Westminster when she telephoned soon after the GP appointment: This reading is not recorded in the telephone note and the parents were not told to bring Eddie back to hospital: (3) The evidence was that scalding injuries amongst children are very common but that toxic shock syndrome is very rare. In their evidence the hospital witnesses helpfully considered whether the information leaflet could be reviewed so as to assist other health professionals who may be less aware of the potential significance of high temperature following a burn and the availability of 24 hour telephone advice the burns unit,

Responses

1 respondent

Chelsea and Westminster Hospital NHS Trust

NHS Trust

Letter dated 25 Oct 2019 PDF

AI-classified response stance Noted

AI-generated response summary

• The Trust has alerted the Paediatric Burns Network to the coroner's advice.

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Dear Mr Barlow, Master Edward (Eddie) Joyce(RIP) Inquest 4 May 2018 The Trust is in receipt of the Regulation 28: Report to Prevent Futures Deaths notice (PFD made by you on 9 May 2018 and issued to Trust and to General Practitioner Further to our earlier correspondence and your clarification of 26 July can confirm the following as the Trust's response which focuses issues identified as directly of concern to the Trust It is the Trust's understanding that the evidence from Nurse explained the action that would have been taken if a spike in temperature was mentioned during the relevant telephone call but there was no suggestion that a spike in temperature was mentioned and not recorded acted on With regard to the national information leaflet; it does set out the warning signs to look out for in a child who has sustained a burns injury and is developing sepsis or Toxic Shock Syndrome (TSS); can confirm that the existing leaflet contains nationally accepted advice in attending to burns injuries in children. It also contains the correct symptoms (red flags) and the correct advice as to what parents ought to do if concerned, including where to seek further treatment and advice_ We have also alerted the Paediatric Burns Network to your advice so that any improvements can be made more widely. We would also to reassure you that our burns unit can already be contacted by telephone 24 hours every day: would also Iike to clarify on behalf of the Trust the PFD notice states at concern (3) that the 'evidence was that scalding injuries amongst children are common but that Toxic Shock Syndrome (TSS) is rare' however we respectfully submit that was clear in her evidence that TSS is very common with approximately one child per on ward monitored for suspected TSS. hope that this response addresses concerns raised but please do not hesitate to contact me directly if there is any further information that you require at this stage

Report sections

Investigation and inquest

On 29 November 2017 commenced an investigation into the death of Edward Joyce age 17 months_ The investigation concluded at the end of the inquest on 4 2018 . conclusion of the inquest was: Medical cause of death: Ia) Septic Shock 1b) Infected burns_ How, when and where the deceased came by his death: Edward Joyce Eddie" = age 17 months, suffered an accidental burn on 19 November 2017 and was treated at Chelsea & Westminster Hospital. On 21 November he was seen by his GP and found to have a temperature of 38.9C. This reading did not trigger a referral back to hospital. On 22 November Eddie's condition significantly deteriorated. He was taken to University Hospital Lewisham where he died despite prolonged attempts at resuscitation Narrative conclusion: Edward Joyce died after developing septic shock from an accidental scalding injury.

Circumstances of the death

Eddie was admitted overnight at Chelsea & Westminster hospital and went home on 20 November: His parents were given an information leaflet and an appointment to be seen again on 23 November: The information leaflet states that a child may need to be seen sooner if show a fever above 38'C or vomiting: On 21 November Eddie's mother took to the GP where he was diagnosed with an ear; throat and eye infection. During the appointment his temperature was noted to be 38.9%C_ After this appointment Eddie's mother telephoned the paediatric burns unit at Chelsea & Westminster,. Her evidence was that she reported the temperature reading at GP of 38.9PC , and that the temperature had now come down to 37.6*C_ The record of this telephone call recorded that the temperature was "37.6 % no higher" and that there had been one small vomit: Neither the GP nor the hospital nurse told Eddie's parents to bring him back to hospital, On 22 November Eddie became severely unwell. His parents telephoned Chelsea & Westminster again and were told to take him to their local A&E department He collapsed as they arrived and died despite attempts at resuscitation.

Action should be taken

In my opinion action should be taken to prevent future deaths and believe you andlor your organisation have the power to take such action:

Similar PFD reports

Shared signals

Report details

Reference: 2018-0142
Date of report: 9 May 2018
Coroner: Philip Barlow
Coroner area: London Inner (South)

Responses identified

Responses identified 1 of 2

1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 6 Jul 2018 (stated in the report).

Sent to

Chelsea & Westminster Hospital

Medical Protection Society

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

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