Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0052, written 21 Feb 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 Feb 2021 |
|---|---|
| Reference | 2021-0052 |
| Deceased | Luke Jackson |
| Coroner | Sonia Hayes |
| Coroner area | Mid Kent and Medway |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Child Death (from 2015) |
| Organisation named | Medway NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
ANNEX A
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
NOTE: This form is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. Matt Hancock – Department of Health
2. Prof
3. Chief Executive Officer Medway NHS Foundation Trust
– Chair Royal College of General Practitioners
1
CORONER
I am Sonia Hayes assistant coroner, for the coroner area of Mid Kent & Medway
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.
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
3
INVESTIGATION and INQUEST
On 20th December 2019 an investigation was commenced into the death of LUKE
OWEN JACKSON, 9. The investigation concluded at the end of the inquest on 7th
October 2020. The conclusion of the inquest was a narrative and the cause of death
1a Hypoxic Ischaemic Encephalopathy due to prolonged Cardiac Arrest 1b
Hypokalaemia 1c Pneumonia II Becker's Muscular Dystrophy, Epilepsy, Post-
Obstructive Hydrocephalus with VP shunt in situ
Luke died on palliative care at the Evelina Children's Hospital on 12th December 2019 of
an Hypoxic Ischaemic Encephalopathy due to prolonged Cardiac Arrest caused by
Hypokalaemia due to Pneumonia. He was transferred from Medway Maritime Hospital on
6th December 2019 following Cardiac Arrest having been admitted on 4th December with
seizures, lower respiratory tract infection and Hypokalaemia. A history of diarrhoea and
vomiting was caused by diversion of blood away from the gut as physiological
compensation rather than infection. His Becker's Muscular Dystrophy and complex history
meant that Luke was unable to correct his potassium as he had lower muscle mass and
this resulted in total potassium depletion and raised heart rate. Luke's cardiac arrest was
avoidable had his Hypokalaemia been appropriately recognised, managed, and treated in
hospital.
1
4
CIRCUMSTANCES OF THE DEATH
Luke had a complex medical history with Becker’s Muscular Dystrophy (later confirmed on
genetic testing) and was being treated for a chest infection. He was admitted to Medway
Hospital with a lower respiratory chest infection and acute gastroenteritis 4 December 2019
He had a fever, tachycardia and hypokalaemia (deficiency of potassium in the bloodstream)
with high lactate treated with IV fluids with potassium and antibiotics. Further fluids were
prescribed without potassium. On the evening of 05 December, Luke was started on
humidified oxygen for mild respiratory distress and his oxygen levels were being monitored.
A blood gas was requested, it was not performed. IV fluids were restarted (without
potassium). His arm was noted to be very floppy. Luke went into cardiac arrest whilst an
inpatient at 06:55 on 06 December 2019 from which he was resuscitated and transferred to
the PICU at Evelina Children’s Hospital the same day where he was treated and later died
on palliative care.
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 could occur unless action is taken. In the
circumstances it is my statutory duty to report to you.
The Trust has taken action to address the conclusions of its Root Cause Analysis and has
learned and disseminated lessons, improving its processes. This Report is made to assist
learning in the public interest as evidence was heard from a consultant from a specialist
children’s hospital that total body potassium depletion is not always recognised in children
with myopathies who become unwell. They may present with diarrhoea and vomiting due to
shunting of the blood away from the gut to protect vital organs such as the brain and heart.
The MATTERS OF CONCERN are as follows: –
(1) Luke had complex needs and was awaiting results of genetic testing confirmed as
Becker’s Muscular Dystrophy. He had not been eating and drinking, had loose stools
and vomiting that had progressed over a five-day period in a background of a chest
infection. His parents had sought and followed medical advice from the hospital by
telephone. Luke continued to deteriorate, and he was admitted. The Trust took some
steps on admission to address his low potassium.
(2) Evidence was heard from a Consultant from the Evelina Children’s Hospital that they
get almost 2000 referrals a year and many have diarrhoea and vomiting as a first
symptom. Issues relating to metabolic derangement in a child with myopathies is not
always recognised as total body potassium depletion and that treatment may need to
be undertaken in intensive care due to the increased amounts of potassium required to
correct the derangement and manage clinical risks:
(i)
(ii)
(iii)
(iv)
Children with Myopathies - have low muscle mass that compromises their
ability to correct their own potassium levels when unwell.
Luke had a chest infection, however his low potassium made him weaker and
as it progressed, he was shunting blood away from his gut to compensate (this
assists to protect the vital organs such as the heart and brain) which resulted
in loose stools and vomiting; this was not a consequence of gastroenteritis.
One of the early symptoms of this shunting process is a high heart rate.
A bolus of potassium and fluid resuscitation to treat gastroenteritis was not
sufficient to treat total body potassium depletion which requires a central line
with significant potassium replacement in intensive care to manage clinical
risk.
Development of a chest infection requires a child to breath harder and this
becomes more difficult in a child with myopathies that is already weakened due
to low potassium and will not present with the usual symptoms of respiratory
distress.
2
(v)
As Luke was treated with oxygen therapy, the monitor alarm set for oxygen
(iv)
(v)
Development of a chest infection requires a child to breath harder and this
becomes more difficult in a child with myopathies that is already weakened due
to low potassium and will not present with the usual symptoms of respiratory
distress.
As Luke was treated with oxygen therapy, the monitor alarm set for oxygen
saturations did not sound as his oxygen did not deplete and he went into
cardiac arrest.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you and your
organisation 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 19th April 2021. 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
representative for Guy’s & St. Thomas’ NHS Foundation Trust. I have also sent it to
(parents of Luke) and
(legal
(Evelina London Children’s Hospital) and
(Medway Hospital) who may
find it useful or of interest.
I am under a duty to send a copy of your response to the Chief Coroner and all
interested persons who in my opinion should receive it.
I may also send a copy of your response to any other person who I believe may find it
useful or of interest.
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.
9
Signature:
Sonia Hayes Assistant Coroner Mid Kent and Medway
21st February 2020
3
3 responses 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.
From Jo Churchill MP Parliamentary Under Secretary of State for Primary Care and Health Promotion Sonia Hayes HM Assistant Coroner, Mid-Kent and Medway Cantium House County Hall Sandling Road Maidstone Kent ME14 1XD 39 Victoria Street London SW1H 0EU 14 May 2021 Dear Ms Hayes Thank you for your letter of 1 March 2021 to Matt Hancock about the death of Luke Owen Jackson. I am replying as Minister with responsibility for child health and I am grateful for the additional time in which to do so. Let me start by saying how deeply sorry I am for the failings in care highlighted in your report. That your investigation found that Luke’s cardiac arrest was avoidable had he received the right treatment for Hypokalaemia is extremely distressing and I offer my most heartfelt sympathies to Luke’s parents and all those affected by his death. Clearly, we must take the learnings from Luke’s death to ensure patients continue to receive the very best care from the NHS. In preparing this response, my officials have made enquiries with NHS England and NHS Improvement (NHSEI); the National Institute for Health and Care Excellence (NICE); and the Royal College of Paediatrics and Child Health (RCPCH). I am informed that in its response to your report, the Medway NHS Foundation Trust has explained the action it has taken to update its paediatric guidelines in relation to patients with myopathies. This is to include the factors that doctors need to be aware of in clinical presentation; the requirement for patients to be fully assessed prior to discharge by at least a Registrar level clinician; and, to make clear the low threshold for admission to high dependency and the level of monitoring and potassium replacement that should be undertaken. I am pleased to note the actions taken by the Trust. It is vitally important that the Trust takes all possible learnings from Luke’s death, and that learnings are also taken forward nationally. In relation to guidance that is available to clinicians, I am advised by NICE that it has issued guidance on intravenous fluid therapy in children and young people in hospital (NG291), updated in June 2020. While the guideline does not give recommendations relating to specific conditions, it provides advice on assessment (including checking electrolytes) before starting intravenous (IV) fluids (see recommendation 1.2.3)); and, recommends that plasma electrolyte concentrations are measured using laboratory tests when starting IV fluids (and then at least every 24 hours, or more frequently as indicated (see recommendation 1.2.4)). The recommendations in this guideline represent the view of NICE, arrived at following careful consideration of the evidence available. When exercising their judgement, clinicians are expected to take this guideline fully into account, alongside the individual needs of their patient. However, it is not mandatory to apply the recommendations, and the guideline does not override the responsibility of clinicians to make decisions appropriate to the specific circumstances of the individual. I am advised that the choice of fluid, the frequency with which electrolyte concentrations are measured after starting IV fluids, and the subsequent escalation of care, depend on the clinical picture and ongoing assessment. It is the view of NICE that the current general guidance about assessment, monitoring, and altering care as indicated is appropriate. Raising awareness among clinicians of how to recognise and manage hypokalaemia in children with myopathies is essential. I am aware that the RCPCH has shared your report with the British Paediatric Neurology Association (the BPNA) and that in its response to you, the RCPCH has explained the existing courses run by the RCPCH and the BPNA, aimed at health professionals, on the recognition and management of neuromuscular disorders. I am also pleased to note that the RCPCH will consider further work to raise awareness of the issues raised by Luke’s death and to promote the current NICE guidance on replacement fluid therapy in children and young people. I hope this response is helpful. Thank you for bringing these important matters to my attention and once again I offer my sincere condolences to Luke’s family. JO CHURCHILL 1 Overview | Intravenous fluid therapy in children and young people in hospital | Guidance | NICE
Medway Maritime Hospital Windmill Road Gillingham Kent ME7 5NY OFFICE OF THE CHIEF MEDICAL OFFICER 30 March 2021 Sonia Hayes Assistant Coroner Mid Kent and Medway Coroners Cantium House County Hall Sandling Road Maidstone Kent ME14 1XD Dear Ms Hayes, Prevention of Future Deaths Regulation 28 Report – Luke Jackson We refer to your report issued following the inquest touching upon the death of Luke Jackson dated 24 February 2021 pursuant to Regulation 28 of the Coroner’s (Investigations) Regulations 2013. (1) Luke had complex needs and was awaiting results of genetic testing relating to Becker’s Muscular Dystrophy. He had not been eating and drinking and had loose stools and vomiting that had progressed over a five-day period on a background of a chest infection. His parents had sought and followed medical advice from the hospital by telephone. Luke continued to deteriorate, and he was admitted. The Trust took some steps on admission to address his low potassium. (2) Evidence was heard from a Consultant from the Evelina Children’s Hospital that many children among their 2000 referrals each year have diarrhoea and vomiting as a first symptom. Metabolic derangement in a child with myopathy may be associated with total body potassium depletion: children with myopathies have a low muscle mass that compromises their ability to correct their own potassium levels when unwell. This is often not well recognised by treating clinicians. Treatment for this condition may need to be undertaken in intensive care due to the increased amounts of potassium required to correct the derangement and manage clinical risks. (3) Luke had a chest infection, however his low potassium made him weaker and as it progressed, he was shunting blood away from his gut to compensate (this assists to protect vital organs such as the heart and brain) which resulted in loose stools and vomiting that were not a consequence of gastroenteritis. One of the early symptoms of this shunting process is a high heart rate. In addition, development of a chest infection requires a child to breath harder and this is more difficult in a child with myopathies who is already weakened due to low potassium and who may as a result not present with the usual symptoms of respiratory distress. The following is our response in relation to the matters of concerns raised: The Trust has updated their Paediatric Guidelines (GUDPCM016) in response to patients with myopathies to reflect that: • All doctors must be aware that… o These patients are likely to have a low muscle mass and that a low serum potassium may indicate underlying deficit in total body potassium o Chest infection can lead to blood redistribution from the gut (leading to diarrhoea and vomiting) and so mimic gastroenteritis o Respiratory compromise may not show by typical symptoms and signs. • These patients must be fully assessed by a Registrar or above (in common with oncology patients) before discharge. • These patients must have a low threshold for admission to HDU with full cardiac monitoring, saturation monitoring and potassium replacement. All children admitted to HDU are now discussed with the South Thames Retrieval Service (STRS) as a matter of course. The Trust has also updated their Paediatric Guidelines with regards to the indications for contacting the STRS in children with hypokalemia and contacting STRS. Our STRS link, Dr who has agreed that STRS do not expect to be contacted for all children with a serum K < 3.0. The use of dilute peripheral solution for potassium remains safe and first line option in District General Hospital settings in appropriately chosen patients. Yours sincerely, Dr Chief Medical Officer Appendix 1. Action Plan Appendix 1. Action Plan Ref Action/Recommendation Outcome for patient when implemented Action Owner: Progress notes: 1 2 3 4 Ensure abnormal results are recognised and escalated to Consultant. Improved monitoring enabling better management and care to be delivered. Paediatric Consultant Develop a guideline for recognition and management of low K+ on the paediatric ward. Improved monitoring enabling better management and care to be delivered. Paediatric Consultant Amend medical handover sheets to highlight abnormal results in bold Improved monitoring enabling better management and care to be delivered. Paediatric Consultant Consultant and nurse in charge to ensure structured handover every time. Improving the quality of handover ensures accurate information including management plans, is conveyed to relevant teams. Paediatric Consultant/ Matron Abnormal results, particularly electrolyte abnormalities are highlighted at hand-over. Handover includes abnormal electrolyte results. Consultant oversees handover twice daily on weekdays and once daily over the weekend. Examples of recent awareness – two patients with low potassium and guidelines followed within same shift. Example of awareness – Datix incident forms completed by senior nurse prior to next handover with immediate action taken by medical staff. The full algorithm has been prepared and was ratified through clinical governance procedure. Page 94 and 95 of Paediatric Guidelines. Completed and uploaded to QPulse (Trust document management system) in January 2021 and updated March 2021. Junior doctors and nurses are reminded at every handover to highlight abnormal or concerning results. Completed and reviewed twice daily (weekdays) and once daily (weekends) by consultant. This is an on-going practice and will be reinforced to all colleagues. Morning handover (including weekends) is led by consultant and nurse in charge (as per rota). Night handover (including weekends) is led by specialty registrar and nurse in charge (as per rota). Weekday evening handover, led by consultant and nurse in charge (weekdays 5pm as per rota). To be highlighted at Induction. Participation of Consultants and nurses in Simulation exercises has improved. Through Nurse Study days and other training. Awareness of good record keeping written on handover sheet, and reviewed at each handover. Junior doctors to undergo European paediatric life support training as soon as they start in the Trust. Earlier recognition leads to better monitoring and management with better outcome. Paediatric Consultant / Senior Resuscitation Officer / Consultant Anaesthetist & Simulation Lead Enhances recognition and management of dehydration. Matron 5 6 7 Awareness and improved accuracy of documentation of input and output. Children with myopathy a. Ensure awareness of doctors that increased risk of low muscle mass, low total body potassium, chest infection can cause gut blood redistribution, and atypical respiratory symptoms and signs of compromise b. Be fully assessed with a low threshold for admission to High Dependency unit for full cardiac and saturation monitoring, by a Registrar or above, noting higher risk for respiratory Improved safety for vulnerable group by increased awareness and increased monitoring by senior doctors in team Paediatric Consultants and Paediatric Registrars Completed update of Paediatric guidelines (version 6.8) uploaded to QPulse March 2021. compromise c. Be assessed for worsening PEWS (observation score) by the Registrar or above d. Managed appropriately based on a-c.
Monday, 19 April 2021 Sent by email to: Dear Assistant Coroner S Hayes Re: Luke Owen Jackson Regulation 28 – Action to Prevent Future Deaths We have read carefully your report regarding the tragic and untimely death of Luke Jackson and have discussed this with senior colleagues within the RCPCH. The RCPCH supports, educates and develops paediatricians, and the wider child health workforce and services, to deliver high quality safe care for infants, children and young people. Given that we do not have all the details of the tragic death of Luke Jackson, the RCPCH is unable to comment on the specifics of the case. We have shared this report with the British Paediatric Neurology Association (BPNA) to raise awareness on recognising and managing Hypokalaemia for patients with reduced muscle mass with aim of acting to prevent future deaths. The RCPCH and BPNA run a variety of courses aimed at the broad spectrum of health professionals caring for children; including primary care professionals, secondary paediatric trainees and doctors, and for specialty professionals. We refer the coroner’s attention to this suite of education provision and are committed to reviewing and updating these courses with a view to promoting best practice and raising the standard of medical care provided to children. • RCPCH - How to Manage: Recognising neuromuscular disorders1 • BPNA distance Learning Unit 5 - Neuromuscular Disorders2 • BPNA Approaching Children's Tone3 We will be discussing with our British Paediatric Surveillance Unit the suggestion of hosting a webinar to increase awareness of this case and to promote current NICE guidance on replacement fluid therapy in children and young people in hospital. 4 1 https://www.rcpch.ac.uk/education-careers/courses/rcpch-course/how-manage-recognising-neuromuscular- disorders-free-online-jul-2021 2 https://www.rcpch.ac.uk/education-careers/courses/specialty-group-course/bpna-distance-learning-unit-5- neuromuscular 3 https://courses.bpna.org.uk/index.php?page=tone-management We will also be meeting with the Neonatal and Paediatric Pharmacist Group to discuss case-based discussion podcasts and will work through our Medicines Committee to consider the issues from this report in any future planning. We recognise that medication errors are a significant but preventable cause of harm to children and young people, and we have convened resources via our MedsIQ and Quality Improvement web hubs to improve alerting and information sharing for members and the broader child health profession.5 6 Our partnership programme Medicines for Children provides practice and reliable advice to parents and families to ensure good quality and reliable information is made available.7 Thank you for raising this case with us and reminding us of the importance of this work. Yours sincerely Professor President, Royal College of Paediatrics and Child Health 4 https://www.nice.org.uk/guidance/ng29/resources/algorithms-for-iv-fluid-therapy-in-children-and-young- people-in-hospital-set-of-6-pdf-2190274957 5 https://qicentral.rcpch.ac.uk/e-poster_category/medsiq/ 6 https://qicentral.rcpch.ac.uk/medsiq/ 7 https://www.medicinesforchildren.org.uk/
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