Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0156, written 21 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 | 21 May 2018 |
|---|---|
| Reference | 2018-0156 |
| Deceased | Alfie Scambler-Holt |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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: Chief Executive of NHS England, Secretary of
State for Health.
1 | CORONER
{am Alison Mutch, Senior Coroner, for the coroner area of South Manchester
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 5" June 2017 | commenced an investigation into the death of Alfie Scambler-Holt.
The investigation concluded on the 8° May 2018 and the conclusion was one of;
Narrative: Died as a consequence of an overwhelming infection on a background of
cerebral palsy,
The medical cause of death was; 1a Sepsis; 1b Respiratory Tract Infection; II Cerebral
Palsy
Alfie Scambler-Holt had cerebral palsy and complex health needs as a result. On 3rd
June 2017, just after 10.00, his mother went in to his bedroom and found he was very
unwell. He had been well at 03.00. An ambulance was called and arrived within 10
minutes. Sepsis was suspected and he was transferred to Stepping Hill Hospital.
Stepping Hill Hospital were on standby for his arrival. He was treated for suspected
sepsis. His PEWS score was 8. The initial intravenous access tissued out after 50m! of
fluid had been administered. Repeated unsuccessful attempts over an hour were made
to gain access before the doctors were successful and antibiotics could be
administered. He was transferred to the Paediatric Unit. His care was supervised by the
registrar. He was not seen by a consultant. His PEWS score was 6 and his blood gas
results showed high lactate and sodium levels indicating kidney compromise. He was
treated with fluid boluses being administered. Fluid output levels were monitored
through nappies rather than catheterisation. His PEWS score dropped to 4. His blood
gas results remained high.
A discussion with the on call consultant resulted to the agreement on the management
plan. A consultant review in person was not carried out. At 20.00 on 3rd June 2017 his
PEWS score rose to 6 and he was examined by the Registrar who prescribed a saline
nebuliser in addition to the fluids prescribed. A 21.05, he suddenly stopped breathing.
A prolonged attempt to resuscitate him was unsuccessful and he died at Stepping Hill
Hospital on 3rd June 2018 from sepsis - 11 hours after his admission.
wi]
| 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 inquest heard that since the death of Alfie Scambler -Holt the Trust had
done a significant amount of work looking at PEWS scores and escalation
processes. The Clinical Lead for Paediatrics told the inquest that one of the
challenges was that there was no national PEWS scoring system. As a result
there were different PEWS scoring systems in operation in different trusts. This
meant that staff dealing with children and moving/rotating between Trusts
would not necessarily be dealing with the same system and escalation
processes.
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.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 16" 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
1 have sent a copy of my report to the Chief Coroner and to the following interested
Persons — mother of the deceased, who may find it useful
or of interest.
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.
ay aS
Alison Mutch OBE Mh |
HM Senior Coroner (| 4
21/05/2018 Ih
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