Source · Prevention of Future Deaths

Kate Pierce

Ref: 2017-0312 Date: 31 Oct 2017 Coroner: David Lewis Area: North Wales (East & Central) 1 response identified · 1 indexed addressee View PDF

AI-generated concerns summaryThere is uncertainty regarding the necessity of a senior paediatrician review before discharging a child when parents request a second opinion. The report also identifies insufficient clear criteria for learning lessons from re-presentations.

Date 31 Oct 2017

56-day deadline 26 Dec 2017 stated in the report

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

There is uncertainty regarding the necessity of a senior paediatrician review before discharging a child when parents request a second opinion. The report also identifies insufficient clear criteria for learning lessons from re-presentations.

View full coroner's concerns

do so having taken into account the contents of written submissions sent to me by and on behalf of the Health Board on 4 October 2017 _ (1) There remains uncertainty about the circumstances in which a sick child should be seen by a senior Paediatrician (Registrar or above) prior to discharge. During the hearing was shown a document headed 'Guidance to Paediatric Junior Doctors on Discharge [sic] Children From Assessment Unit' which was given to understand reflects current practice and represents an improvement on the positon in 2006. The information in the letter of 4 October 2017 is broadly consistent with it_ Both documents are silent as to whether a parental request for a second opinion should automatically lead to an examination of the child by the senior doctor_ as was opined in court; where the importance and significance of parents' views were noted. am concerned that a lack of clarity about the Health Board's expectations in this respect may continue to allow for the possibility of a child being discharged without a sufficient (and sufficiently senior) assessment having be made (2) heard evidence at length from the Health Board's current Clinical Lead for Paediatrics about (inter alia) the measures which are in place to ensure that lessons can be learnt (and acted upon) promptly when things do not go to plan_ Specifically heard about steps taken to learn lessons from situations in which a child might re-present in a worse condition following an earlier discharge situation which might result a missed diagnosis did not emerge from this evidence with any confidence that there exist clearly defined and consistently applied criteria from ensuring that learning opportunities are being actively sought out acted upon: For example, was told that there is no defined list of triggers; with much Ieft to judgement of individuals in the senior management team_ This evidence, supplemented by the relevant contents of the letter of 4 October 2017 , leaves me concerned that too much is left to chance in the identification of matters requiring investigation; in the selection of the investigating staff and in the urgency of lessons learnt and acted upon The current system might therefore warrant a review (perhaps including consideration of best practice elsewhere, in other hospitals outside the Health Board) to see whether grounds for improvement exist.

Responses

1 respondent

University Health Board

Letter dated 15 Dec 2017 PDF

AI-classified response stance Action Taken

AI-generated response summary

• The Health Board confirmed it has a formal policy for discharging children from the assessment unit, which is discussed during departmental induction. • The Health Board stated it would alter parent discharge information to explicitly state that parents may escalate their desire for a second opinion.

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Dear Mr Gittins Regulation 28 Letter in respect of Kate Pierce Thank you for your recent Regulation 28_ We found your comments helpful and having considered them write to confirm our acceptance of them: Further to your enquiry about the current process regarding the decision to discharge children from the children's assessment unit at Wrexham Maelor Hospital, can confirm the Health Board has a formal policy which is discussed with all doctors at departmental induction (see enclosed): In short, no child can be discharged by a doctor with less than 6 months paediatric experience without discussion with, or reviewed by a middle grade (tier 2) doctor. AlI doctors are instructed to record this information in the patients notes: For tier 1 doctors with more than 6 months paediatric experience they are allowed to discharge patients. However , this authority is not extended to all doctors, but reviewed by the consultant paediatrician_ We have debated the issue of whether to explicitly state that parents may escalate their desire to have a second opinion. Views are mixed on this. Whilst we are confident that the culture of the department is such that a parental request or indeed concern from any member of staff would lead to a consultant review, we taken the decision to alter the parent discharge information to explicitly state this. trust this is helpful:

Report sections

Investigation and inquest

On 25th March 2013 HM Senior Coroner commenced an investigation into the death of Kate Louise Pierce ('Kate') The investigation concluded at the end of the inquest on 22 September 2017 which was heard by me sitting with a jury. The jury's conclusion of the inquest was that Kate died from natural causes to which neglect contributed: The medical cause of death was: (a) Acquired cerebral palsy with epilepsy and chronic lung disease (b) complications of pneumococcal meningitis

Circumstances of the death

On 29 March 2006 Kate was unwell, presenting with a range of non-specific symptoms_ The out-of-hours GP on telephone advised that she should be seen in person by the out-of-hours GP_ In turn, after examining Kate at the surgery, the latter referred her on to Wrexham Maelor Hospital for further assessment: She was seen first by a Paediatric Nurse and a short time later by a Senior House Officer. The latter diagnosed viral tonsillitis_ jury found that Kate had remained asleep and did not respond throughout doctor' s examination. Kate's parents believed that the junior doctor had taken a second opinion from a senior colleague (which supported the junior doctor's diagnosis) before Kate was discharged at about midnight on 29/30 March 2006, with an offer of 24/7 open access back to the department should her condition deteriorate. Following a deterioration in Kate's condition her parents returned her t0 the hospital at around midday on 31 March 2006,about 36 hours later. Thereafter it was quickly determined that she had developed pneumococcal meningitis. She was transferred for specialist care at Alder Hospital, where tests confirmed the diagnosis and also revealed that she had Para-Influenza Virus Type IIl (which was likely to have been present on the evening of 29 March and may have been responsible for some of her symptoms at the time_of her first presentation) the The the Hey

As a result of the meningitis Kate suffered brain damage and other health conditions which persisted throughout her short life and were responsible for her death, in Florida, on 19 March 2013. Kate's death did not result in any formal or meaningful investigation by the Hospital until after it had received a letter of complaint Kate's family some months after the events in March 2006_ This compromised the quality and reliability of the memory of witnesses

Action should be taken

In my opinion action should be taken to prevent future deaths and | believe you and your organisation have the power to take such action. from delay from and being

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Shared signals

Report details

Reference: 2017-0312
Date of report: 31 October 2017
Coroner: David Lewis
Coroner area: North Wales (East & Central)

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 26 Dec 2017 (stated in the report).

Sent to

Betsi Cadwaladr University Health Board

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

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