Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0078, written 14 Mar 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 Mar 2018 |
|---|---|
| Reference | 2018-0078 |
| Deceased | Freddie Dobinson-Evans |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Child Death (from 2015) · Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Barts and the London NHS Trust · Homerton University Hospital 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: Prevention of Future Deaths report
Freddie Oliver DOBINSON-EVANS (died 10.04.17)
THIS REPORT IS BEING SENT TO:
1. Dr Lucy Jenkins
Director
North East Thames Regional Genetics Laboratory
Great Ormond Street Hospital for Children
Levels 5 & 6 Barclay House
37 Queen Square
London WC1N
2.
Consultant in paediatric neurology
Royal London Hospital
Whitechapel High Road
London E1 1BB
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 21 April 2017, one of my assistant coroners, Edwin Buckett,
commenced an investigation into the death of Freddie Dobinson-Evans,
aged one year. The investigation concluded at the end of the inquest on
1 March 2018.
I made a determination at inquest of death by natural causes.
I recorded a medical cause of death of:
1
1a post cardiac arrest syndrome
1b Dravet syndrome
4
CIRCUMSTANCES OF THE DEATH
Freddie’s Dravet syndrome was not diagnosed in life. At the time of his
death he was being investigated, and a diagnosis of complex febrile
convulsions had been made by his treating clinicians.
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.
Following a testing request made for Freddie on 20 February 2017, a
report was issued from the laboratory at Great Ormond Street Hospital
on 7 June 2017. It was headlined:
No clearly pathogenic variant detected. Diagnosis not confirmed.
spoke to Freddie’s father the following day and told him that
Freddie’s genetic test results were “absolutely normal”.
In fact, Freddie did have a pathogenic gene mutation in the SCN1A gene
and died as a result of Dravet Syndrome.
By the time the report was issued, Freddie had already sadly died and
so of course the misdiagnosis had no consequences for him, but such a
situation could have significant consequences for another child.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that 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 14 May 2018. I, the coroner, may extend the
period.
2
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 following.
HHJ Mark Lucraft QC, the Chief Coroner of England & Wales
Care Quality Commission for England
Homerton University Hospital NHS Trust
Barts and The London NHS Trust
, Freddie’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 Senior Coroner, at the time of your response,
about the release or the publication of your response by the Chief
Coroner.
9
DATE SIGNED BY SENIOR CORONER
14.03.18
3
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.
Barts Health NHS Trust Paediatric Neurology Department 8th floor Paediatric Offices The Royal London Hospital London, E1 1BB Telephone: 020 73777000 ext. 42476 www.bartshealth.nhs.uk Ms Mary Elizabeth Hassell Senior Coroner for Inner North London St Pancras Coroner’s Court Camley Street London N1C 4PP 11/05/2018 Dear Ma’am, Inquest touching the death of Freddie Dobinson Evans I write in response to a Regulation 28, Report to Prevent Future Deaths, dated 14 of April 2018, which was made at the conclusion of the inquest into the death of Freddie Dobinson Evans. Barts Health NHS Trust takes Coronial investigations very seriously and I am sorry you have had to make Preventing Future Death recommendations and I am grateful to you for highlighting your concerns. The concerns you have raised in the Preventing Future Death report are: 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: Following a testing request made for Freddie on 20 February 2017, a report was issued from the laboratory at Great Ormond Street Hospital on 7 June 2017. It was headlined: No clearly pathogenic variant detected. Diagnosis not confirmed. him that Freddie’s genetic test results were “absolutely normal”. In fact, Freddie did have a pathogenic gene mutation in the SCN1A gene and died as a result of Dravet Syndrome. By the time the report was issued, Freddie had already sadly died and so of course the misdiagnosis had no consequences for him, but such a situation could have significant consequences for another child. spoke to Freddie’s father the following day and told Following actions were taken: 1. I have communicated with (Clinical Scientist and director of the genetics lab. GOS hospital), who had promptly responded to my email. 2. On 24/04/2018, a meeting was held at the Lab. between (GOS hospital Lab manager) and myself , Consultant paediatric neurologist), 3. had listened carefully to the concerns and agreed that there are changes in the results format that was on the way and will be effective from 01/05/2018. 4. These changes were initiated in response to the inquest recommendation for prevention of future deaths. 5. I was shown the new results’ template; The new template clearly addresses future directions in case of presence of any abnormality. 6. I will ensure that myself and the paediatric neurology team members keep effective communication with the Clinical scientists shall there remain in clarities. Many thanks Consutant paediatric neurologist Royal London hospital.
See every Prevention of Future Deaths report matching Barts and the London 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.