Prevention of Future Deaths reports · 2014

Evelyn Smith

Regulation 28 report to prevent future deaths, reference 2014-0406, written 12 Sep 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report12 Sep 2014
Reference2014-0406
DeceasedEvelyn Smith
CoronerR Brittain
Coroner areaWarwickshire
CategoryHospital Death (Clinical Procedures and medical management) related deaths
Sourcejudiciary.uk record · original PDF
Responses publishednone published

The report

Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS REPORT IS BEING SENT TO:

(1) Mr Richard Jefferson | Head of Business Systems | NHS England

CORONER

lam R Brittain, Assistant Coroner for Warwickshire

CORONER’S LEGAL POWERS

| make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009
and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.

INVESTIGATION and INQUEST

The investigation into the death of Evelyn Mary Smith concluded at the end of the inquest
on 5 September 2014. The cause of her death was Acute Ulcerative
Laryngotracheobronchitis; the conclusion of the inquest was narrative (copy attached).

CIRCUMSTANCES OF THE DEATH

Miss Smith was 7 years old at the time of her death on 13 September 2013. She did not
have a significant past medical history. The illness which resulted in her death began on
11 September 2013. She awoke in the early hours of 12 September with difficulty in
breathing. This prompted her mother to take her to the Accident and Emergency (A&E)
Department at Warwick Hospital (part of South Warwickshire NHS Foundation Trust), She
was seen by a Foundation Year 2 (FY2) doctor who had 8 weeks undergraduate and n
postgraduate experience in paediatrics. This doctor diagnosed Miss Smith as having ‘viral
croup’ and prescribed steroid medicine (Dexamethasone). Miss Smith was discharged
after the FY2 doctor discussed her case with a more senior ‘Specialty A&E Registrar’.

Both doctors were reassured that her vital signs were improving, although she did have

persisting fever and a heart rate above the normal range.

Later on the 12 September 2013 Miss Smith’s family arranged for her to be reviewed at he!
GP practice because of ongoing concerns. She was seen by an Advanced Nurse
Practitioner, who diagnosed tonsillitis and prescribed antibiotics. Her respiratory rate,
along with other vital signs, were not documented as part of this consultation.

On 13 September 2013 Miss Smith remained unwell and was taken back to her GP. She
was seen by a doctor who again diagnosed viral croup. Her GP accessed a ‘clinical
mentor’ tool on the practice computer system, which highlighted a scoring algorithm to

classify the severity of croup. Miss Smith was scored as having moderate croup which,
the scoring classification suggests, warranted admission to hospital. However, after
treatment with a Salbutamol nebuliser (instituted because of a recent insect sting), Miss

Smith's GP felt that she had improved and prescribed a further course of oral steroid!

medication (Prednisolone). She was not admitted to hospital and returned home.

Whilst at home later on 13 September, Miss Smith suffered an acute deterioration in her
breathing, at which point she had a cardiac arrest. Despite the institution of early
resuscitation and rapid transfer to hospital by paramedics, it was not possible to revive her
and she was pronounced dead at Warwick Hospital.

A post-mortem examination demonstrated the presence of a virus (Parainfluenza Virus
Type 2) and a bacterium (Staphylococcus Aureus) as infectious organisms, which resulted
in Acute Ulcerative Laryngotracheobronchitis.

CORONER’S CONCERNS

During the course of the inquest the evidence revealed matters giving rise to concern. In
my opinion there is a risk that future deaths may occur, unless action is considered. in the
circumstances it is my statutory duty to report to you.

The MATTERS OF CONCERN are as follows. —-

(1) The care provided to Miss Smith was reviewed by an independent paediatrician and d
General Practitioner. | heard evidence that the accurate and consistent recording of Miss
Smith's vital signs may have allowed earlier recognition of the severity of her illness. | also
heard that the use of the Paediatric Early Warning Scoring system in General Practice
may be a useful way of documenting this information. However, it was clear that
information in this form is not easy to enter into GP medical records.

(2) From the evidence heard at Miss Smith's inquest it was apparent that the scoring
system for croup severity was not widely known amongst the clinicians involved in her
care. However, her GP did learn of this scoring system after reviewing the ‘clinical mentor’
tool through the practice's computer software.

| heard evidence that systems are in place to prompt entry of certain clinical parameters in
specific scenarios; predominantly chronic disease review consultations, such as for
diabetes and asthma etc. | am concerned that the GP computer system contains

important and clinically relevant information, such as the croup severity score but does not
alert the clinician to complete it. | heard that it should be possible to prompt the entry of
relevant clinical parameters after a diagnostic code has been entered into a consultation
record.

ACTION SHOULD BE TAKEN

In my opinion, consideration should be given as to whether action is required to prevent
future deaths. | believe the addressee has the power to make such a consideration and
take appropriate action.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report,
namely by 7 November. I, the coroner, may extend the period.

Your response must contain details of action taken or proposed to be taken, setting out
the timetable for action. Otherwise you must explain why no action is proposed.

COPIES and PUBLICATION

| have sent a copy of my report to the Chief Coroner and to the following Interested

Persons (a) The Smith family, (b) South Warwickshire NHS Foundation Trust and (c) Miss
Smith’s General Practitioners

lam also under a duty to send the Chief Coroner a copy of your response.

The Chief Coroner may publish either or both in a complete or redacted or summary form.
He may send a copy of this report to any person who he believes may find it useful or of
interest. You may make representations to me, the coroner, at the time of your response,
about the release or the publication of your response by the Chief Coroner.

12 September 2014
Assistant Coroner R Brittain
Also filed under 2014-0406: Smith-2014-0406a.pdf
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS REPORT IS BEING SENT TO:

(1) eee | Chief Executive | Health Education England (HEE)

(2) | President | College of Emergency Medicine (CEM)

(3) NEN | President | Royal College of Paediatrics and Child Health
(RCPCH)

CORONER

! am R Brittain, Assistant Coroner for Warwickshire

CORONER’S LEGAL POWERS

| make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009
and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.

INVESTIGATION and INQUEST

The investigation into the death of Evelyn Mary Smith concluded at the end of the inquest
on 5 September 2014. The cause of her death was Acute Ulcerative
Laryngotracheobronchitis; the conclusion of the inquest was narrative (copy attached).

CIRCUMSTANCES OF THE DEATH

Miss Smith was 7 years old at the time of her death on 13 September 2013. She did not
have a significant past medical history. The illness which resulted in her death began on
11 September 2013. She awoke in the early hours of 12 September with difficulty in
breathing. This prompted her mother to take her to the Accident and Emergency (A&E)
Department at Warwick Hospital (part of South Warwickshire NHS Foundation Trust). She
was seen by a Foundation Year 2 (FY2) doctor who had 8 weeks undergraduate and na
postgraduate experience in paediatrics. This doctor diagnosed Miss Smith as having ‘viral
croup’ and prescribed steroid medicine (Dexamethasone). Miss Smith was discharged

after the FY2 doctor discussed her case with a more senior ‘Specialty A&E Registrar’.

Both doctors were reassured that her vital signs were improving, although she did have 4
persisting fever and a heart rate above the normal range.

Later on the 12 September 2013 Miss Smith's family arranged for her to be reviewed at he
GP practice because of ongoing concerns. She was seen by an Advanced Nurse
Practitioner, who diagnosed tonsillitis and prescribed antibiotics. Her respiratory rate,
along with other vital signs, were not documented as part of this consultation.

On 13 September 2013 Miss Smith remained unwell and was taken back to her GP. She
was seen by a doctor who again diagnosed viral croup. Her GP accessed a ‘clinical
mentor’ tool on the practice computer system, which highlighted a scoring algorithm to

. Miss Smith was scored as having moderate croup which,

the scoring classification suggests, warranted admission to hospital. However, after
treatment with a Salbutamol nebuliser (instituted because of a recent insect sting), Miss
Smith's GP felt that she had improved and prescribed a further course of oral steroid
medication (Prednisolone). She was not admitted to hospital and returned home.

Whilst at home later on 13 September, Miss Smith suffered an acute deterioration in her
breathing, at which point she had a cardiac arrest. Despite the institution of early
resuscitation and rapid transfer to hospital by paramedics, it was not possible to revive her
and she was pronounced dead at Warwick Hospital.

A post-mortem examination demonstrated the presence of a virus (Parainfluenza Virus
Type 2) and a bacterium (Staphylococcus Aureus) as infectious organisms, which resulted
in Acute Ulcerative Laryngotracheobronchitis.

CORONER’S CONCERNS

During the course of the inquest the evidence revealed matters giving rise to concern. In
my opinion there is a risk that future deaths may occur, unless action is considered. In the
circumstances it is my statutory duty to report to you.

The MATTERS OF CONCERN are as follows. —

(1) The care provided to Miss Smith was reviewed by an independent paediatrician, whq
raised concerns regarding the paediatric experience of the FY2 doctor in A&E. His
concern was that, whilst the care provided was not manifestly inappropriate or incorrect,
he considered that discussion with the paediatric team may have prompted a longer period
of observation and consideration of non-viral causes of croup-like signs. | share his
overarching concern that a doctor, relatively inexperienced in paediatrics, should be the
only clinical contact for a child taken to A&E.

| heard from the Hospital Trust that mandating all FY2 doctors to have postgraduate
experience in paediatrics, before they were allocated to work in A&E, might have
significant resource implications and may not be feasible.

ACTION SHOULD BE TAKEN

In my opinion, consideration should be given as to whether action is required to prevent
future deaths. | believe the addressees have the power to make such a consideration and
take appropriate action.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report,
namely by 7 November. I, the coroner, may extend the period.

Your response must contain details of action taken or proposed to be taken, setting out
the timetable for action. Otherwise you must explain why no action is proposed.

COPIES and PUBLICATION

| have sent a copy of my report to the Chief Coroner and to the following Interested
Persons (a) The Smith family, (0) South Warwickshire NHS Foundation Trust and (c) Miss
Smith's General Practitioners

lam also under a duty to send the Chief Coroner a copy of your response.

The Chief Coroner may publish either or both in a complete or redacted or summary form.
He may send a copy of this report to any person who he believes may find it useful or of
interest. You may make representations to me, the coroner, at the time of your response,
about the release or the publication of your response by the Chief Coroner.

12 September 2014
Assistant Coroner R Brittain

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