Summary
A was admitted to A&E at the Royal Hospital for Sick Children with symptoms including retching, a purple rash on their leg and feeling agitated. A had a diagnosis of quadriplegic cerebral palsy (form of cerebral palsy in which all four limbs are affected), was non-verbal and received PEG feeding (passing a thin tube through the skin to give food, fluids and medicines directly into the stomach). A was subsequently admitted to hospital after assessment.
A was observed in hospital and underwent a number of investigations. A gastrojejunal tube (when a thin, long tube is threaded into the jejunal portion of the small intestine) was inserted to address concerns about A's nutrition. A became increasingly distressed following the procedure and their condition deteriorated. A underwent emergency surgery where a caecal volvulus (obstruction of the bowel) was diagnosed.
C complained to the board that they had missed several opportunities to diagnose and treat the bowel obstruction which was causing A's symptoms. The board produced a report detailing the history of A's care and decision making during the period. The main finding was that there were no identified failings in the care provided to A and that there was no misdiagnosis of A's condition.
Dissatisfied with the board's response to the complaint, C brought their complaint to our office. We took independent advice from a paediatric gastroenterologist (a doctor specialising in the treatment of conditions affecting the liver, intestine and pancreas) and a paediatric radiologist (a specialist in the analysis of images of the body). We found that the investigations and treatment provided were appropriate. There was a delay in obtaining a CT scan, however the delay was relatively small in the context of the period of A's admission. As such, we found that the care and treatment provided to A was reasonable and we did not uphold the complaint.
There were some aspects of care which we identified as being suitable to feedback to the board for reflection and consideration.
Related reading
View Decision Report 201909705 as a PDF (24.8 KB) Updated: June 22, 2022