Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0234, written 27 Sep 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 27 Sep 2017 |
|---|---|
| Reference | 2017-0234 |
| Deceased | Peter Kollar |
| Coroner | Andrew Harris |
| Coroner area | London Inner (South) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Child Death (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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 THIS REPORT IS BEING SENT TO: 1. President, Royal College of Paediatrics and Child Health, 5- 11 Theoboalds Road, WC1 8SH 2. Mr Gordon Miles, Chief Executive, Royal College of Emergency Medicine, 7-9 Bream’s Buildings, Chancery Lane, London EC4A 1DT CORONER I am Andrew Harris, Senior Coroner, London Inner South jurisdiction CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. INQUEST On 16th December 2016, I opened an inquest into the death of: Master Peter Kollar who died aged 3 ¥%, on 14th May 2015 at King’s College Hospital (01351-15) (MM) It was concluded on 6th June 2017, The medical cause of death was: la Multi-organ failure with pulmonary haemorrhage ib Acute liver failure Ic Unidentified inborn error of metabolism Il Viral infections The conclusion was natural causes. CIRCUMSTANCES OF THE DEATH The child presented to AGE in a local hospital with diarrhoea and jaundice. He was diagnosed by a locum paediatric registrar with carotenemia despite his parents evidence that he disliked carrots. He was not admitted and sent home against the wishes of his parents, without a blood test or any investigation. He was not escalated for opinion by a consultant and one of the reasons was a normal Paediatric Early Warning Score (PEWS). CORONER’S CONCERNS During the coutse of the inquest, the evidence revealed a matter giving rise to concern that in my opinion means that there is still a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTER OF CONCERN is as follows. - Professor of Paediatric Hepatology, Birmingham gave an expert opinion. She said that jaundice is rare in children after the neonatal period and that its seriousness was under recognised by both paediatricians and emergency doctors. She considered that, whilst it made no difference to the outcome in this case, the non escalation of a young child with jaundice to a suitable specialist adversely affects their care and is potentially life threatening. There will be instances when a child presents with a primary liver cause of hepatic failure where prompt referral for support and the possibility of organ transplantation was critical. ACTION SHOULD BE TAKEN | recommended that your joint Royal Colleges should be notified of the tisk of future deaths occurring through under recognition of the seriousness of jaundice and her recommendation that jaundice should be added to the Paediatric Early Warning Score as a matter requiring immediate escalation. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by Wednesday, 22 November 2017. 1, the coroner, may extend the period. Your response must contain details of action taken ot proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. If you require any further information or assistance about the case, the case ocr aii please contact COPIES and PUBLICATION Ihave sent a copy of my report to the following Interested Persons: (parents) SE consultant Royal Berkshire Hospital Tam also sending this report to the following, who may have an interest: Department of Health Tam 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. [DATE] [SIGNED BY CORONER] 27- Y-1) ,
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 College of Emergency Medicine Patron: HRH Princess Royal 7-9 Bream's Buildings Tel +44 (0)20 7404 1999 London Fax +44 (0}20 7067 1267 EC4A IDT www.rcem.dc.uk DrA Lb nad Southwark Coroners Court 4h fag thdpe 1 Tennis Street Southwark of } SE1 1YD 1 November 2017 . Dear Dr Harris, Re: Preventing Future Deaths Report for Master Peter Kollar Thank you for asking the Royal College of Emergency Medicine to consider this tragic case. We are committed to learning from cases where there have been bad outcomes. , The specific question we have been asked to consider is whether the presence of jaundice should be added to the Paediatric Early Warning Score (PEWS). This question was discussed in detail at the most recent meeting of the Quality Emergency Care Committee of the Royal College. This group is comprised of around 30 experienced Consultant Emergency Physicians with specific expertise in patient safety and best practice. Early Warning Scores are usually developed by rigorous primary research studies. The presence of jaundice after the immediate neonatal period is rare. Many other features that would indicate a seriously ill child are not part of the PEWS, such as abnormal cry or bulging fontanelle. Early Warning Scores are never designed to replace clinical judgement, but merely indicate to a clinician that the patient may be ill. The group unanimously concluded that it would not be justifiable or effective fo amend the Paediatric Emergency Warning Score to include jaundice. Yours sincerely, ~~ Gla I, 7 oo fle Gordon Miles Chair, Quality in Emergency Chief Executive Care Committee Excellence in Emergency Care Incorporated by Royal Charter, 2008 VAT Reg. No: 173205823 Registered Charity number 1122689 Scottish Charity number $C044373
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