Source · Prevention of Future Deaths

Peter Kollar

Ref: 2017-0234 Date: 27 Sep 2017 Coroner: Andrew Harris Area: London Inner (South) 1 response identified · 2 indexed addressees View PDF

AI-generated concerns summaryThe coroner noted an under-recognition of the seriousness of jaundice in children beyond the neonatal period by medical professionals, highlighting that non-escalation to specialists can adversely affect care and be life-threatening, particularly where urgent referral for transplantation is needed.

Date 27 Sep 2017

56-day deadline 22 Nov 2017 est. estimated from the report date

Responses identified 1 of 2

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

Coroner's concerns

AI summary

The coroner noted an under-recognition of the seriousness of jaundice in children beyond the neonatal period by medical professionals, highlighting that non-escalation to specialists can adversely affect care and be life-threatening, particularly where urgent referral for transplantation is needed.

View full coroner's concerns

In the circumstances it is my statutory to report to you The MATTER OF CONCERN is as follows. Professor of Paediatric Hepatology, Birmingham gave an expert opinion. She said that jaundice is rare in children after the neonatal period and that its seriousness was under recognised by both paediatricians and emergency doctors. She considered whilst it made no difference to the aged May` duty that, outcome in this case, the non escalation of a young child with jaundice to a suitable specialist adversely affects their care and is potentially life threatening: There will be instances when a child presents with a primary liver cause of hepatic failure where prompt referral for support and the possibility of organ transplantation was critical,

Responses

1 respondent

The Royal College of Emergency Medicine

Education

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AI-classified response stance Noted

AI-generated response summary

• The Royal College of Emergency Medicine's Quality Emergency Care Committee discussed the inclusion of jaundice in the Paediatric Early Warning Score (PEWS). • The committee concluded that amending the PEWS to include jaundice would not be justifiable or effective.

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Dear Dr Harris Re: Preventing Future Deaths Report for Master Peter Kollar Thank YoU for asking the Royal College of Emergency Medicine to consider this tragic case. We are committed to learning from cases where there have been bad outcomes_ The specific question we have been asked to consider is whether the presence of jaundice should be added to the Paediatric Early Warning Score (PEWS) This question was discussed in detail at the most recent meeting of the Quality Emergency Care Committee of the Royal College. This group is comprised of around 30 experienced Consultant Emergency Physicians with specific expertise in patient safety and best practice_ Early Warning Scores are usually developed by rigorous primary research studies. The presence of jaundice after the immediate neonatal period is rare. Many other features that would indicate & seriously ill child are not part of the PEWS, such aS abnormal cry or bulging fontanelle. Early Warning Scores are never designed to replace clinical judgement; but merely indicate to a clinician that the patient may be ill, The group unanimously concluded that would not be justifiable or effective to amend the Paediatric Emergency Warning Score to include jaundice_

Report sections

Investigation and inquest

On I6th December 2016,1 opened an inquest into the death of; Master Peter Kollar who died 3 Vz, on 14th 2015 at King' s College Hospital (01351-15) (MM) It was concluded on 6th June 2017. The medical cause of death was: la Multi-organ failure with pulmonary haemorrhage 1b Acute liver failure Ic Unidentified inborn error of metabolism II Viral infections The conclusion was natural causes_

Circumstances of the death

The child presented to A&E in a local hospital with diarrhoea and jaundice. He was diagnosed by a locum paediatric registrar with carotenemia despite his parents evidence that he disliked carrots_ He was not admitted and sent home against the wishes of his parents, without a blood test or any investigation. He was not escalated for opinion by a consultant and one of the reasons was a normal Paediatric Early Warning Score (PEWS).

Action should be taken

recommended that your joint Royal should be notified of the risk of future deaths occurring through under recognition of the seriousness of jaundice and recommendation that jaundice should be added to the Paediatric Early Warning Score as a matter requiring immediate escalation.

Copies sent to

1) Colleges her duty days duty

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Shared signals

Report details

Reference: 2017-0234
Date of report: 27 September 2017
Coroner: Andrew Harris
Coroner area: London Inner (South)

Responses identified

Responses identified 1 of 2

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 22 Nov 2017 (estimated from the report date).

Sent to

Royal College of Emergency Medicine

Royal College of Paediatrics and Child Health

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

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