Source · Prevention of Future Deaths

Rasharn Williams

Ref: 2015-0168 Date: 29 Apr 2015 Coroner: ME Hassell Area: London North (Inner) Responses identified: 1 / 1 View PDF

The patient's care plan was unclear regarding emergency actions for breathlessness, potentially causing ambiguity for staff. A vital medical instruction notice for the child was also not displayed due to transitional arrangements.

Date 29 Apr 2015

56-day deadline 24 Jun 2015 est.

Responses identified 1 of 1

Child Death (from 2015) Other related deaths

Coroner's concerns

AI summary

View full coroner's concerns

1. Whilst staff at the school were clear that they should call an ambulance in the case of an emergency, and I heard evidence from the first aider that she would have called an ambulance immediately if she had thought Rasharn was having a seizure, Rasharn’s care plan was not wholly clear on this point.

The plan described breathlessness as an emergency. I appreciate that this may have had its origin with Rasharn’s treating clinicians. However, his exercise tolerance was reducing all the time and so breathlessness was, to a degree, a feature of his condition. Extreme breathlessness coupled with low oxygen saturations would be a different matter, but this was not made clear in the plan.

This potential lack of clarity did not have an impact on the outcome in this particular situation, but it might in another. It seems that your care plans may benefit from some review to ensure that there is no ambiguity unwittingly created for those attempting to follow them.

2. I heard that some schools have notices with a child’s photograph and particular instructions regarding medical conditions, displayed in the staff room, office and medical room.

Rasharn did have such a notice, but it was only in the medical room, and was not actually displayed at the time of his death, because of transitional arrangements regarding a move of premises.

Again, this did not have an impact on the outcome for him, but might for another child.

Responses

1 respondent

Berger Primary School Education

PDF

Action Taken

Berger Primary School has reviewed care plans, will refer unclear emergency provisions to school nurse/consultant, and amended its policy to ensure clarity in emergency situations. They will place photos and summaries of children with severe medical conditions in the staff and medical rooms. (AI summary)

View full response

MATTER: RASHARN WILLIAMS MATTER NO: 780901 CLIENT CODE: G4597 RESPONSE TO REGULATION 28 PREVENTION OF FUTURE DEATH REPORT FOR RASHARN WILLIAMS (DIED 23 OCTOBER 2014) Response of Mr Head Teacher at Berger Primary School, Anderson Road, London E9 6HB. HM Coroner raised concerns regarding clarity of emergency situations on the Child Healthcare Plan: We have undertaken review of all existing care plans and in particular reviewed the emergency provisions If the emergency is not clear as to what constitutes an emergency for the child and the action to be taken then the appropriate SENCO will refer the matter back to the school nurse and/or the hospital consultant for clarification. The policy for the Education for Children with Medical Needs will be amended to include: if an individual Healthcare Plan is not clear as to what is regarded as an emergency for the child and the action to be taken, the member of staff responsible will clarify these provisions with the school nurse and/or the hospital contact identified on the Healthcare Plan. The school will ensure that all children with severe medical conditions will have their photograph and summary of their condition and treatment placed in the staff room and the medical room: This will be based upon those children who have to: (a) Use an Epi Pen for their condition; (b) Administer medicine; (c) Epilepsy or seizures; Page of 2 Lezan /3156932.1

(d) More serious illnesses Healthcare Plans affect 15% of the children thus those who work with particular child with Healthcare Plan are made aware of that child' s condition and the treatment required. It would not be possible to exhibit all the children who are subject to a Healthcare Plan on the staff room wall and medical room. In addition children who have food allergies have their pictures in the kitchen so they are not provided with food to which are intolerant to. These arrangements were in force prior to the transitional arrangements regarding the move of premises and are now in force with additional photographs in the staff room: Signed: Dated: 2Lleb4Ls_ Legall13156932.1 of 2 they Pare

Report sections

Investigation and inquest

On 29 October 2014, one of my assistant coroners, Richard Brittain, commenced an investigation into the death of Rasharn Williams, aged 9 years.

The investigation concluded at the end of the inquest on 24 April 2015, when I made a determination that Rasharn died from natural causes.

His medical cause of death was:

1a hypoxia 1b generalised seizure 1c univentricular cyanotic congenital heart disease with pulmonary hypertension

Circumstances of the death

Rasharn’s cardiologist had not expected him to live to adulthood, but had not expected him to die this quickly. He was a little boy who enjoyed life and engaged with it fully, despite his heart problem. Upon the direction of his doctors and with the agreement of his mother, Rasharn was allowed to participate in school activities, but then to sit out when he felt tired.

On 23 October 2014, he was having fun at a school disco when he became fatigued and sat down. He was noticed by a teacher who approached him. He began to cry and was breathless and distressed, so she took him into the school office to sit down. This was at approximately 4.30pm. Rasharn’s mother was telephoned and asked to come in to school.

After a while, Rasharn appeared to improve a little, and the teacher left him with two members of the administrative staff. One of these was a permanent member who was also a first aider, and one was a more junior, temporary member who was not a first aider but, coincidentally, had looked after a little boy with epilepsy in the past.

Approximately seventeen minutes after being brought in to the office, at around 4.47pm, Rasharn deteriorated and became somewhat absent. The junior member of staff suspected him to be having a seizure and asked if an ambulance should be called. The first aider did not think this was a seizure and so formed the view that an ambulance should not be called.

Despite the fact that Rasharn had never suffered a seizure before, and was not thought to be particularly at risk of seizures, the likelihood is that this was a seizure from which he never really recovered, and that he later had more seizure activity.

His mother arrived three minutes after the seizure began, at around 4.50pm. Four minutes after that, at 4.54pm, the first aider called an ambulance. The ambulance arrived at 5.03pm. While Rasharn was in the back of the ambulance but still on the premises, at 5.14pm, he suffered a cardiac arrest. He was treated and transferred to hospital, arriving at 5.19pm.

Rasharn was treated aggressively in hospital, but died later that evening. It is unclear whether earlier medical intervention could have changed the outcome on this particular occasion.

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Report details

Reference: 2015-0168
Date of report: 29 April 2015
Coroner: ME Hassell
Coroner area: London North (Inner)

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: 24 Jun 2015 (estimated).

Sent to

Berger Primary School

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.