Kirsty Childs

On 9th January 2013, this jurisdiction commenced an investigation into the death of Kirsty Childs, Age 20. The investigation concluded at the end of the inquest on 7th April 2016. The conclusion of the inquest was a narrative verdict:- Kirsty Louise Childs died at home septic shock caused by an undiagnosed and untreated mesenteric venous thrombosis. Kirsty her mother telephoned NHS Direct on a number of occasions between 31 December 2012 and 2 January 2013 for advice and assistance due to a range of symptoms which Kirsty was displaying Despite these telephone conversations Kirsty was not admitted to hospital If she had been admitted to hospital by the morning of 1 January 2013 and received definitive hospital care, the likelihood is that would have survived_ The cause of death was:- la) Septic Shock b) Small Bowel Infarction c) Superior Mesenteric Venous Thrombosis

Kirsty Childs was a 20 year old single parent who lived with her 2 year old daughter and parents in Denby Dale, Huddersfield. She had no significant medical history and was not on any prescribed medication. On Christmas 2012, she reported to her parents as not feeling well but with no specific symptoms_ On Sunday 3Oth December she began to experience severe abdominal pain, sickness and diarrhoea. Her mother contacted NHS Direct (the out of hours service operating at the time) at 20.35 hours on 31st December, because her daughters symptoms were Mary from and Kirsty Day worsening-This was the first of 18 phone calls made ad received by Kirsty and her family with NHS Direct; the Ambulance Service and the out of hours GP service, over the next 2 days in an attempt to obtain appropriate advice and care for Kirsty: The initial call was taken by a Health Adviser (as all initial and repeat calls were to the service): The Health Adviser (who not medically qualified) in undertaking an assessment selected the incorrect computer generated questionnaire, which resulted in the call being given lower priority for a call back by a Nurse Adviser. Kirsty's mother phoned the service again at 1.09 hours, now Ist January, as no call back had been received_ The Health Adviser did not appear to undertake a review of the record made of the initial telephone call (something which appeared to be the case on phone call to the service) but proceeded to undertake new assessment: Kirsty's mother was advised that a Nurse Adviser would call back within 1 hour. In fact, a call was received by a Nurse Adviser within half an hour. Kirsty was asked to detail her symptoms which she did, and added that she had noticed blood in her bowel motion and describes her bowel motion as really dark brown: The Nurse Adviser also worked through pre-determined computer generated questionnaire, selected after hearing the patient's symptoms and identifying the most serious The Nurse Adviser concluded that Kirsty was suffering from and she should self -care, and advised that if her symptoms worsened, she should phone the service back: heard evidence from an independent Vascular Surgeon that the Nurse Adviser should have asked more questions surrounding the presence of blood in Kirsty's bowel motion. He indicated that if these questions had been asked it should have become clear that Kirsty was not suffering from a gastrointestinal bug, and that arrangements should have been made for Kirsty to be reviewed by a Doctor, either assessed at home by the emergency out of hours General Practitioners service, Or, referred to her local Accident and Emergency Service. He confirmed that if this had happened, it is likely that Kirsty would have been admitted to hospital, undergone investigations and diagnosed with her actual condition, a superior mesenteric venous thrombosis, which he considered at this stage was treatable and it is likely Kirsty would have survived Kirsty herself contacted NHS Direct 4 hours later at 5.45 hours, reporting that her symptoms had worsened, she had noticed blood in her vomit and she was very Once again, the call was taken by a Health Adviser who did not appear to review the record of earlier calls made_ new assessment using selected pre determined questionnaire was made. Kirsty endeavoured to answer the questions asked of her. She reported symptoms of feeling cold, but at the same time sweating and feeling clammy, which are recognised symptoms of shock: The Health Adviser endeavoured to put the call though to Nurse Adviser without success: A Nurse Adviser phoned back quickly. Kirsty reported symptoms of very severe abdominal pain which was getting worse, blood in her last bowel movement and in the last half hour had vomited dark red blood, although she had been sick subsequently with no blood present, her skin felt cold, but she was perspiring: every again being bug being dizzy. very

The Nurse Adviser appears not to have reviewed previous records of earlier calls_ She chose to override the recommended conclusion of the selected questionnaire which was that Kirsty should attend an Accident and Emergency Department: She advised Kirsty that she was suffering from a and should self-care_ independent Vascular Surgeon expert who gave evidence indicated that he would have expected Kirsty to have been referred to hospital and if she had, it is likely she would have survived_ No call was made by or her family to NHS Direct during the course of the on the Ist January. Kirsty spent most of the in bed, her symptoms continued she was not eating, she occasionally was being sick, but was endeavouring to sip fluids. During the afternoon Kirsty's mother found her on the floor near her bedroom. She appeared very weak At 1.00 am, now the 2nd January, Kirsty asked for her mother' s further help to take her to the toilet: As she assisted her, Kirsty had a vacant expression, she had difficulties breathing and she was unable to stand Her mother proceeded to phone NHS Direct again: The call was once again taken by a Health Adviser who followed the same procedure as in previous calls. Kirsty was having difficulty answering the Advisers questions: decision was taken for Kirsty to be further reviewed over the telephone by a Nurse Adviser. A subsequent internal review identified that not all questions from the pre-determined questionnaire were asked. If they had been, the internal review concluded that Kirsty may have been referred to Accident and Emergency: Kirsty received a call back from a Nurse Adviser. Once again, no review of earlier call information appears to have taken place_ Kirsty was required to provide all information afresh: She described her vomit as being black throughout the The Nurse Adviser stated that Kirsty needed to be taken to Accident and Emergency to be reviewed. The Nurse Adviser made no enquiry if anyone was able to transport Kirsty to hospital, and the call was ended abruptly. Neither of her parents were able to take her to hospital, and Kirsty described feeling too weak to make the journey: Her mother therefore phoned for an ambulance, the call was taken by a Emergency Medical Dispatcher (who is not medically qualified) The equivalent to the Health Adviser within the NHS Direct service. Kirsty's mother made it clear at the beginning of the conversation that NHS Direct had directed that Kirsty should attend Accident and Emergency. However, the Emergency Dispatcher did not have the authority to despatch an ambulance based upon the recommendation of NHS direct. Once again, Kirsty was asked to describe her symptoms, in order that the most appropriate questionnaire was chosen and answered: subsequent internal review confirmed that an incorrect questionnaire was selected. If the correct one had been chosen, evidence given at the inquest indicated that an ambulance would have been despatched to respond within minutes. As it was the incorrectly chosen questionnaire directed a referral to a Clinical Adviser. Kirsty received a call back at 2.32 2nd January from a Clinical Adviser. It was made clear to them by Kirsty' $ mother that NHS direct have recommended hospital attendance_ Questions were asked, but not all of Kirsty's symptoms were identified. Once again general questions were followed by a selected questionnaire. The answers resulted in a recommendation of attendance at Accident and Emergency as soon as possible bug The Kirsty day day day:

However; the Nurse Adviser chose to override the recommended course to be followed as she considered that Kirsty was suffering from a Norovirus viral infection and that she should not attend Accident and Emergency, she thought it best that Kirsty should not attend an Accident and Emergency unit; because there may be a lengthy delay in her seeing a doctor. She therefore advised that Kirsty should phone her own GP practice to arrange an out of hours GP review: West Yorkshire Ambulance Service had no direct arrangements with the out of hours GP service The Nurse Adviser, therefore, had no means of ensuring that Kirsty would be seen by a doctor and no knowledge of how quickly this would occur_ As result Kirsty and her family were being referred to completely separate organisation who had no direct access to details of the of pre existing calls made and received. The independent Vascular Surgeon, who gave evidence at the inquest, indicated that by this stage Kirsty was critically ill. She should have been admitted to hospital, but, if she had been it is unlikely she would have survived_ Kirsty's mother then endeavoured to seek further help for her daughter. A recorded message at her GP'$ provided contact details for West Yorkshire urgent care a service which was provided co-incidentally at the time by a section of NHS Direct_ What Kirsty and her family were expecting is for an out of hours GP to attend their home What actually happened was exactly the same process as had already happened on numerous occasions already. Health Adviser taking the call, and proceeding through questionnaire process, with no access or review or previous computerised details recorded Once again subsequent internal review identified that the wrong questionnaire was selected resulting in a lower prioritisation being applied. Once Nurse Adviser rang the family, From the transcripts of the calls it is identified Kirsty was having difficulties breathing: The Nurse Adviser was made aware that previous calls had been made. The Nurse Adviser advised that someone would ring the family back: When this call occurred the family were offered an appointment at a GP in centre some miles from their home: The family explained that Kirsty was not well enough to attend and was now incapable of standing: The family ask if a GP could make a domiciliary visit, were advised this was not possible. Kirsty and her family decided to wait until the following morning to contact their own General Practitioners_ The independent Vascular Surgeon indicated that even if Kirsty had been reviewed and admitted to hospital, her underlying condition was so advanced that direct medical intervention is unlikely to have saved her. The following morning Kirsty's mother looked in on Kirsty, she appeared asleep and therefore did not disturb her_ She contacted their GP practice and requested domiciliary visit A GP attended a short time later and identified that Kirsty had in fact died.

In my opinion action should be taken to prevent future deaths and believe you [ANDIOR your organisation] have the power to take such action.