Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0038, written 2 Feb 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 Feb 2016 |
|---|---|
| Reference | 2016-0038 |
| Deceased | Ryan Singh Bhogal |
| Coroner | Zafar Siddique |
| Coroner area | Black Country |
| Category | Community health care and emergency services related deaths · Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | The Royal Wolverhampton NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. 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. Practice Manager, Lockfield Surgery, Croft/Gomer Street, Willenhall, West Midlands, WV13 2DR 2. Chief Executive, New Cross Hospital, Wolverhampton Road, Wolverhampton, West Midlans,WV10 0QP 1 CORONER I am Zafar Siddique, Senior Coroner, for the coroner area of the Black Country. 2 CORONER’S LEGAL POWERS I 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. 3 INVESTIGATION and INQUEST On 25 September 2015, I commenced an investigation into the death of Baby Ryan Singh Bhogal. The investigation concluded at the end of the inquest on 29 January 2016. The conclusion of the inquest was the deceased died by way of natural causes on the 11 September 2015 from 1a. Hypotensive Shock 1b. Acute Myeloid Leukaemia with t(9;11)(p22;q23)KMT2A-MLLT3 4 CIRCUMSTANCES OF THE DEATH 1. During the course of the inquest over two days, I heard evidence that Ryan was born on the 9 January 2014 and was by all accounts a thriving and healthy baby and toddler during the early part of his life. Like any other child he would pick up colds and coughs which were fairly routine and as responsible parents they would seek advice from their GP or Walk in centre staff as necessary. He began crawling at around 8 months and hit all his key developmental targets and was up to date with immunisations. To all intents and purposes he was a thriving healthy baby boy. 2. The frequency of visits to their GP was increasing and from the 17 September 2014 to the 7 September 2015 there were over 20 visits. In addition there were several visits to walk in centres and five visits to New Cross Hospital. On each occasion, he presented with various symptoms including raised temperature, history of falls, and was seen by various Health professionals from Junior to Senior Doctors including Consultant Paediatricians and Advanced Practitioner Nurses. 3. On the vast majority of occasions, he was diagnosed with a vial illness including tonsillitis and the parents were reassured and given painkillers and antibiotics to treat him as necessary. 4. We also heard evidence that on more than one occasion, the parents described symptoms of bleeding gums, puffy eyes, unexplained bruising to his leg and the development of a lump appearing on his head lasting for several weeks. 1 [IL1: PROTECT] 5. We heard descriptions of “Red flags” for Leukaemia and with hindsight, the General Practitioner representing the surgery, accepted that there may have been “missed opportunities” and that partly, due to the lack of continuity in respect of which GP saw him may have played a factor in not picking up potential red flags earlier and seeking a second opinion or requesting a blood test. 6. We also heard in evidence that he visited New Cross Hospital a number of times. We heard in evidence from the various clinicians who treated Ryan specifically from the period 25 July 2015 through to 9 September 2015. In particular, on the 25 July, Ryan presented with a history of fever for three days and we are told there was no evidence of any enlargement of the liver or spleen. There were no signs of rash and he was eventually discharged home with paracetamol. 7. He was readmitted on the 27 July and he had developed a cough and blanching rash on his neck, back and chin. He also had a red inflamed throat and elevated pulse. This was diagnosed as oral thrush and a viral infection and he was discharged after one set of observations. Again no blood tests were ordered. When I asked the question, whether the Hospital staff had access to GP records, the answer was yes; however, they would only be accessed if there was a valid reason to do so, for example, a safeguarding concern and the records themselves would sometimes appear upside down. medical opinion was that had a blood test been done on the 7 September it is possible that Leukaemia could have been diagnosed. It is not clear if that earlier diagnosis would have made a material difference to the outcome. 8. Ryan then returned on the 7 September and when examined he was found to have a slightly distended abdomen. He also had a raised pulse and his throat was red with exudates on his right tonsil. We heard he was subsequently discharged again when his pulse rate had improved. 9. He was then admitted to the Paediatric Assessment Unit at the same Hospital and a full blood test was requested and it was noted that the liver and spleen were enlarged. Blood tests later showed metabolic acidosis and low blood sugar levels. The results for the blood test were available at around 4.30pm (they were requested at 1pm). At this stage the true extent of Ryan’s condition was realized and a proposed diagnosis of Acute myeloid Leukaemia. 10. Both parents were spoken to shortly after 6pm and he was then transferred to Birmingham Children’s Hospital. Urgent chemotherapy treatment was started but sadly Ryan deteriorated rapidly and passed away on the 11 September 2016. 11. It was not clear on the balance of probability if an earlier diagnosis or blood test in August or September would have made a difference to the outcome because this type of Leukaemia is a particularly aggressive form of the disease with a survival rate of around 40 per cent. 5 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 will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – 2 [IL1: PROTECT] 1. There was a lack of continuity and overall ownership in terms of treatment Ryan received at the GP practice. He was seen by different Doctor’s including Locum staff with no overall holistic approach. This surgery may wish to consider reviewing their policy and management of children who appear excessively for treatment to ensure that there is continuity of care and appropriate measures are in place. In addition you may wish to consider reviewing the systems in place in identifying “Red Flags” and seeking a second opinion or requesting further tests where symptoms or unexplained illnesses are identified for an extended period. 2. The Royal Wolverhampton NHS Trust may wish to consider reviewing their policy in in relation to when it is appropriate to review GP medical records during Hospital admissions. This is particularly important for young children in order to have a clearer history of the patient’s presentation before reaching a diagnosis and treatment regime. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 30 March 2016. 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons, Ryan’s parents, I am 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. 9 2 February 2016 3 [IL1: PROTECT]
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
The Royal Wolverhampton INHS NHS Trust New Cross Hospital Wolverhampton | West Midlands WV10 0QP Mr Zafar Siddique HM Senior Coroner Black Country Coroner’s Office Smethwick Council House High Street Smethwick B66 3NT 29 March 2016 Dear Mr Siddique RE: REGULATION 28: REPORT TO PREVENT FUTURE DEATHS — INQUEST & INVESTIGATION INTO THE DEATH OF BABY RYAN SINGH BHOGAL, CONCLUDED 29" JANUARY 2016 | write in response to your report to prevent future deaths regarding the case of baby Ryan Singh Bhogal whose death was subject to an inquest concluding on 29" January 2016. The matter of concern raised relating to The Royal Wolverhampton Trust was as follows: “The Royal Wolverhampton NHS Trust may wish to consider reviewing their policy in relation to when it is appropriate to review GP medical records during hospital admissions. This is particularly important for young children, in order to have a clearer history of the patient’s presentation before reaching a diagnosis and a treatment regime.” The Royal Wolverhampton NHS Trust will introduce a Standard Operating Procedure (SOP) across the Trust, providing guidance to all Clinicians to ensure that relevant information relating to individual patients is taken into account during the patient's initial assessment and subsequent hospital admission (should the patient be admitted). The SOP will reinforce the requirement to question all patients (and where appropriate relatives and other individuals) about medical care and investigations and advice sought, and the necessity to access and review relevant records relating to the patient, including GP medical records, The Royal Wolverhampton NHS Trust clinical records and/or any other relevant information held by other organisations (having gone through the relevant channels and process). The purpose of accessing this information is to ensure that relevant information is taken into account when assessing, managing and treating the patient. The SOP will apply to all patients treated at the Trust, including babies, children and adults. Chairman: Jeremy Vanes Chief Executive: David Loughton CBE Preventing Infection — Protecting Patients A Teaching Trust of the University of Birmingham Continued ....... The SOP will be approved, authorised and implemented across the Trust by 30 June 2016. Following approval and implementation, | will send you a copy of the SOP for your attention. Additionally, we plan to audit compliance against the SOP 6 months following implementation, and | will forward the results of this audit and any actions arising to you as well. Please do not hesitate to contact me if you require any further information. Yours sincerely ae 7h An MEDICAL DIRECTOR
See every Prevention of Future Deaths report matching The Royal Wolverhampton NHS Trust, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.