Source · Prevention of Future Deaths
Emmanuel Akinmuyiwa
Ref: 2014-0421
Date: 26 Sep 2014
Coroner: Louise Hunt
Area: Birmingham & Solihull
Responses identified: 0 / 3
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The absence of a clear regional protocol for sickle cell disease management led to staff lacking knowledge of crisis symptoms and necessary treatment, compounded by funding issues.
Date
26 Sep 2014
56-day deadline
21 Nov 2014 est.
Responses identified
0 of 3
Coroner's concerns
The absence of a clear regional protocol for sickle cell disease management led to staff lacking knowledge of crisis symptoms and necessary treatment, compounded by funding issues.
View full coroner's concerns
Evidence at the inquest confirmed that there needed to be a clear protocol in the West Midlands for the management of patients with Sickle cell disease. Ordinarily are managed at Birmingham Children's hospital. In this case as Emmanuel was admitted to Heartlands hospital various telephone calls were made to Birmingham Children's hospital, It was acknowledged in an internal investigation by Birmingham Heartlands hospital that staff had a lack of knowledge and appreciation for the signs and symptoms due boy they of a sickle cell crisis and what treatment was necessary. was informed at the inquest that clinicians would prefer a hub and spoke approach to treatment of sickle cell disease with clear guidelines and protocols for how and where patients should be treated was informed that this had not happened to date due to the lack of funding available to liaise with all local hospitals and produce and put in place such protocol and guidance A lack of guidelines and protocols for the West Midlands means future patients are at risk of death_
Report sections
Investigation and inquest
On 18/02/13 commenced an investigation into the death of Emmanuel Tobiloba Akinmuyiwa The investigation concluded at the end of the inquest on 12 September 2014. The conclusion of the inquest was that the deceased died from 1a. Cardiac failure due to 1b. Severe anaemia to Ic sickle cell disease. recorded a narrative conclusion as follows; Emmanuel died on the 11mh February 2013 as a result of severe anaemia caused by a sickle cell crisis. During his admission there was a gross failure to check his HB on 10/02/13 and a failure to provide an earlier blood transfusion. On balance earlier monitoring of his haemoglobin and an earlier blood transfusion would have avoided his death: His death was contributed to by neglect
Circumstances of the death
Emmaunel was a 7 year old who suffered from sickle cell disease. On 08/02/13 he was referred to Birmingham Heartlands Hospital and found to have a HB of 5.7_ He was diagnosed as being in sickle cell crisis. On 09/02/14 his HB was 5. Instructions were left that he should have a further blood test taken on 10/02/13. junior doctor decided not to undertake that test as Emmanuel looked clinically well. On 11/02/13 his HB was checked. The result was available at Apm and confirmed a level of 2.8. At 20.30 he was given a transfusion At 21.50 he got up to toilet and collapsed He could not be resuscitated and died,
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action_
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Report details
- Reference
- 2014-0421
- Date of report
- 26 September 2014
- Coroner
- Louise Hunt
- Coroner area
- Birmingham & Solihull
Responses identified
Responses identified
0 of 3
3 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 21 Nov 2014 (estimated).
Sent to
- Birmingham and Solihull Clinical Commissioning Group
- Commissioning groups
- NHS England