Barts Health NHS Trust
NHS / Health Body
Action Taken
Barts Health NHS Trust has reviewed and approved contingency plans for laboratory analyser faults, and implemented a system of rotational consultant checks to ensure results are chased. They clarified that ketone meters are available but their use for neonatal hypoglycaemia requires further review, and confirmed existing practice for chasing inpatient results. (AI summary)
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Dear Ma'am,
Response to Regulation 28 into the death of Caliel Smith-Kwame
Thank you for forwarding the Preventing Future Death Report to me for the Trust's consideration. I am grateful to you for highlighting some of the issues that came to your attention during the hearing. The points you have raised have been considered by Dr Vadivelam Murthy, Consultant and Clinical Lead for Neonatal Medicine and Dr Ruth Ayling, Consultant Biochemist.
1. The insulin results were delayed, due to a fault with the analyser. Clinicians were not notified by the lab that the analyser was not functioning. No alert was sent out. Contingency plans could have been put in place to ensure that alternative arrangements were made for the test to be analysed before Caliel was discharged from hospital. The independent expert was critical of the lab's failure to notify clinicians.
Since this incident the Laboratory has been through a UKAS inspection and has been recommended for accreditation. Contingency plans have been reviewed and approved as part of this process and these will be implemented in future.
2. Test results do not appear to have been chased up before Caliel's discharge from hospital. It was unclear from the evidence who had the responsibility for chasing up test results prior to discharge.
The attending team chase the results of all investigations when the child is an inpatient. However, if the test results are only available after discharge these are entered as a pending result in the discharge summary. This is chased at a later date during the outpatient clinic appointment. In this case the child passed away prior to the appointment. Since the time Caliel was a patient, we have developed a more robust system in which a dedicated consultant will chase all the results weekly and undertake appropriate actions based on the results and document them in the electronic patient record. This is done on a rotational basis by each of the consultants to ensure that this is done promptly every week.
Barts Health NHS Trust: Newham University Hospital, The London Chest Hospital, The Royal London Hospital, St Bartholomew's Hospital and Whipps Cross Hospital.
POSITIV ABOUT PEOPLE DISABLED
***
Barts and The London NHS NHS Trust
3. The results of the amino acid profile, which raised the possibility of hyperinsulinism were sent through to the electronic record system on the 9th August 2016. It does not appear that any clinician was aware of this result prior to Caliel's death. The Consultant in charge of Caliel's care stated there was no system in place for the electronic records system for highlighting to clinical staff that results are ready. He said when paper results were in place, clinicians would refer to the paper results, but his has now been lost.
We do not have an electronic system to warn us that the results are available. Some blood tests take weeks before a result is available. It is for the clinician keeping a record of the patient's details and chasing the results. However, we have set up the system of a rotational Consultant carrying out a check as outlined in point two above to act as a further check to ensure this is done.
4. The independent expert stated in the absence of the insulin and amino acid profiles results, a ketone test might have been of assistance with the diagnosis. He stated that ketone tests can be done at the bedside and that this has recently been introduced within the NHS. No witness was able to confirm whether this has been implemented at Barts.
Ketone meters are already available within the Trust and on the unit. However, these meters tend to be used in patients with conditions associated with high blood glucose concentrations and there are a number of issues around their use in neonates with hypoglycaemia which need careful consideration with review of the available evidence base before extending their use to this circumstance. When used, the results are documented in the patient's observation charts.
Response to Regulation 28 into the death of Caliel Smith-Kwame
Thank you for forwarding the Preventing Future Death Report to me for the Trust's consideration. I am grateful to you for highlighting some of the issues that came to your attention during the hearing. The points you have raised have been considered by Dr Vadivelam Murthy, Consultant and Clinical Lead for Neonatal Medicine and Dr Ruth Ayling, Consultant Biochemist.
1. The insulin results were delayed, due to a fault with the analyser. Clinicians were not notified by the lab that the analyser was not functioning. No alert was sent out. Contingency plans could have been put in place to ensure that alternative arrangements were made for the test to be analysed before Caliel was discharged from hospital. The independent expert was critical of the lab's failure to notify clinicians.
Since this incident the Laboratory has been through a UKAS inspection and has been recommended for accreditation. Contingency plans have been reviewed and approved as part of this process and these will be implemented in future.
2. Test results do not appear to have been chased up before Caliel's discharge from hospital. It was unclear from the evidence who had the responsibility for chasing up test results prior to discharge.
The attending team chase the results of all investigations when the child is an inpatient. However, if the test results are only available after discharge these are entered as a pending result in the discharge summary. This is chased at a later date during the outpatient clinic appointment. In this case the child passed away prior to the appointment. Since the time Caliel was a patient, we have developed a more robust system in which a dedicated consultant will chase all the results weekly and undertake appropriate actions based on the results and document them in the electronic patient record. This is done on a rotational basis by each of the consultants to ensure that this is done promptly every week.
Barts Health NHS Trust: Newham University Hospital, The London Chest Hospital, The Royal London Hospital, St Bartholomew's Hospital and Whipps Cross Hospital.
POSITIV ABOUT PEOPLE DISABLED
***
Barts and The London NHS NHS Trust
3. The results of the amino acid profile, which raised the possibility of hyperinsulinism were sent through to the electronic record system on the 9th August 2016. It does not appear that any clinician was aware of this result prior to Caliel's death. The Consultant in charge of Caliel's care stated there was no system in place for the electronic records system for highlighting to clinical staff that results are ready. He said when paper results were in place, clinicians would refer to the paper results, but his has now been lost.
We do not have an electronic system to warn us that the results are available. Some blood tests take weeks before a result is available. It is for the clinician keeping a record of the patient's details and chasing the results. However, we have set up the system of a rotational Consultant carrying out a check as outlined in point two above to act as a further check to ensure this is done.
4. The independent expert stated in the absence of the insulin and amino acid profiles results, a ketone test might have been of assistance with the diagnosis. He stated that ketone tests can be done at the bedside and that this has recently been introduced within the NHS. No witness was able to confirm whether this has been implemented at Barts.
Ketone meters are already available within the Trust and on the unit. However, these meters tend to be used in patients with conditions associated with high blood glucose concentrations and there are a number of issues around their use in neonates with hypoglycaemia which need careful consideration with review of the available evidence base before extending their use to this circumstance. When used, the results are documented in the patient's observation charts.