Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0142, written 9 May 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 May 2018 |
|---|---|
| Reference | 2018-0142 |
| Deceased | Edward Joyce |
| Coroner | Philip Barlow |
| 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.
ANNEX A
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. Chief Executive, Chelsea & Westminster Hospital
/o Medical Protection Society
{1 | CORONER
| am Philip Barlow, assistant coroner, for the coroner area of Inner South London
2 | 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.
3 | INVESTIGATION and INQUEST
On 29 November 2017 | commenced an investigation into the death of Edward Joyce,
age 17 months. The investigation concluded at the end of the inquest on 4 May 2018.
The conclusion of the inquest was:
Medical cause of death: 1a) Septic Shock 1b) Infected burns.
How, when and where the deceased came by his death: Edward Joyce (“Eddie”),
age 17 months, suffered an accidental burn on 19 November 2017 and was treated at
Chelsea & Westminster Hospital. On 217 November he was seen by his GP and found to
have a temperature of 38.9C. This reading did not trigger a referral back to hospital. On
22 November Eddie’s condition significantly deteriorated. He was taken to University
Hospital Lewisham where he died despite prolonged attempts at resuscitation.
Narrative conclusion: Edward Joyce died after developing septic shock from an
accidental scalding injury.
4 | CIRCUMSTANCES OF THE DEATH
Eddie was admitted overnight at Chelsea & Westminster hospital and went home on 20
November. His parents were given an information leaflet and an appointment to be seen
again on 23 November. The information leaflet states that a child may need to be seen
sooner if they show a fever above 38°C or vomiting.
On 21 November Eddie’s mother took him to the GP where he was diagnosed with an
ear, throat and eye infection. During the appointment his temperature was noted to be
38.9°C. After this appointment Eddie's mother telephoned the paediatric burns unit at |
Chelsea & Westminster. Her evidence was that she reported the temperature reading at
the GP of 38,9°C, and that the temperature had now come down to 37.6°C. The record
of this telephone call recorded that the temperature was “37.6 °C - no higher” and that |
there had been one smail vomit. Neither the GP nor the hospital nurse told Eddie’s
parents to bring him back to hospital.
On 22 November Eddie became severely unwell. His parents telephoned Chelsea & |
Westminster again and were told to take him to their local A&E department. He |
collapsed as they arrived and died despite attempts at resuscitation.
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. —
The evidence at the inquest was that a temperature reading above 38°C following a burn
fo a young child is highly concerning, and could be an early sign of septicaemia and
toxic shock syndrome.
(1) The temperature reading of 38.9°C at the GP did not trigger an urgent referral to
hospital.
(2) Eddie’s mother was clear that she reported this temperature reading to the nurse at
Chelsea & Westminster when she telephoned soon after the GP appointment. This
reading is not recorded in the telephone note and the parents were not told to bring
Eddie back to hospital.
(3) The evidence was that scaiding injuries amongst children are very common but that
toxic shock syndrome is very rare. In their evidence the hospital witnesses helpfully
considered whether the information leaflet could be reviewed so as to assist other health
professionals who may be less aware of the potential significance of high temperature
following a burn and the availability of 24 hour telephone advice from the burns unit.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you and/or
your organisation have the power to take such action.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 6 July 2018. |, 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:
The Local Safeguarding Board (because the deceased was under 18)
| 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 May 2018 Philip Barlow
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.
Chelsea and Westminster Hospital NH iS} Cheisea and Westminster Hospital Mr Philip Barlow Chief Executive Office Deputy Coroner for Inner South 369 Fulham Road Southwark Coroner’s Court London 1 Tennis Street Southwark S70 ON SE1 71YD Tel: 020 3315 6711 25 October 2019 Fax: 020 1234 6633 Dear Mr Barlow, Master Edward (Eddie) Joyce(RIP) - inquest 4 May 2018 The Trust is in receipt of the Regulation 28: Report to Prevent Futures Deaths notice (PFD made by you on 9 May 2018 and issued to the Trust and to General Practitioner, Further to our earlier correspondence and your clarification of 26 July | can confirm the following as the Trust’s response which focuses issues identified as directly of concern to the Trust. It is the Trust’s understanding that the evidence from Nurse il explained the action that would have been taken if a spike in temperature was mentioned during the relevant telephone call but there was no suggestion that a spike in temperature was mentioned and not recorded / acted on. With regard to the national information leaflet, it does set out the warning signs to look out for in a child who has sustained a burns injury and is developing sepsis or Toxic Shock Syndrome (TSS); | can confirm that the existing leaflet contains nationally accepted advice in attending to burns injuries in children. It also contains the correct symptoms (red flags) and the correct advice as to what parents ought to do if concerned, including where to seek further treatment and advice. We have also alerted the Paediatric Burns Network to your advice so that any improvements can be made more widely. We would also like to reassure you that our burns unit can already be contacted by telephone 24 hours every day. | would also like to clarify on behalf of the Trust the PFD notice states at concern (3) that the ‘evidence was that scalding injuries amongst children are very common but that Toxic Shock Syndrome (TSS) is very rare’ however we respectfully submit thatJ was clear in her evidence that TSS is very common with approximately one child per day on the ward being monitored for suspected TSS. | hope that this response addresses the concerns raised but please do not hesitate to contact me directly if there is any further information that you require at this stage. Yours sincerely Chief Nurse Chelsea and Westminster Hospital NHS Foundation Trust
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