Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0012, written 18 Jan 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 18 Jan 2022 |
|---|---|
| Reference | 2022-0012 |
| Deceased | Coco Bradford |
| Coroner | Andrew Cox |
| Coroner area | Cornwall and the Isles of Scilly |
| Category | Child Death (from 2015) · Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Information Classification: CONTROLLED REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO 1. , Chief Executive, National Institute for Health & Care Excellence 1 CORONER I am Andrew Cox, the Senior Coroner for the coroner area of Cornwall and the Isles of Scilly. 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. 3 INVESTIGATION and INQUEST On 14/1/22, I concluded an inquest into the death of Coco Bradford, a 6-year-old girl who died in Bristol Royal Hospital for Children on 31/7/17. . The medical cause of death was recorded as: 1a) Multiple organ failure 1b) E-coli 0157 associated Haemolytic Uraemic Syndrome 1c) II) I recorded a Narrative Conclusion that Coco died from natural causes, in particular, a severe form of haemolytic uraemic syndrome, a known but rare complication of an e-coli 0157 bacterial infection. 4 CIRCUMSTANCES OF THE DEATH Coco was a 6-year-old girl with an established diagnosis of autism. On 25/7/17, she presented to the Emergency Department at Royal Cornwall Hospital with diarrhoea and vomiting. It was suspected she had gastroenteritis. She was treated and discharged with standard advice to return if her condition deteriorated. On 26/7/17, she re-presented more unwell. She was admitted with a working diagnosis of bacterial gastroenteritis and, as she had features of shock, she was subsequently given several boluses of IV fluids. Her condition improved temporarily after each bolus, but the improvements were not sustained and over the course of 27/7/17 she progressively deteriorated. Haemolytic uraemic syndrome (HUS) was suspected and confirmed on blood results later that night. There was concern she also had a concomitant sepsis, but this was not demonstrated on blood cultures only reported after her transfer to Bristol. She was transferred to the Intensive Care Unit on the morning of 28/7/17. After resuscitation and stabilisation, she was transferred to the paediatric intensive care unit in Bristol. Despite further treatment, she continued to deteriorate and died at Bristol Royal Hospital for Children on 31/7/2017. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed two 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. 1 Information Classification: CONTROLLED The MATTERS OF CONCERN are as follows. – 1) In April 2009, NICE published CG 84 on Diarrhoea and Vomiting caused by gastroenteritis in Under 5s and management. Paragraph 1.3.3 deals with IV fluid management for patients presenting with shock. The guidance suggests rehydration with rapid IV infusion at 20mls/kg. The guidance is now a little dated and it is at odds with the Resuscitation Council UK Guidelines issued in 2021 which provide that for children and infants presenting with shock, fluid should be given in boluses of 10mls/kg – there is an emphasis on smaller bolus volumes with careful re-assessment after each bolus to enable early identification of signs and symptoms of fluid overload. This was particularly relevant in Coco’s treatment where there was concern she may develop HUS with associated compromise of kidney function. As there appears now to be a move towards smaller boluses of fluid with more frequent review, it may be that you will also feel it appropriate to reconsider when to escalate care to colleagues in intensive care i.e. whether it should still be after two boluses or after a particular total amount of fluid. 2) A second issue that came out of Coco’s inquest was the clinical conundrum of how to treat a child with bacterial (e coli 0157) gastroenteritis who is suspected of having a concomitant sepsis. The dilemma is that the administration of antibiotics may precipitate or worsen HUS and, if the child is subsequently found not to have sepsis, may inadvertently cause harm. It may be that you will feel that guidance on how to weigh the balance of risk and who to involve in the decision-making process would be of assistance to clinicians generally. 6 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. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 15/3/22. 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: Hospital of Bristol and its clinicians. ; Royal Cornwall Hospital and its clinicians; University 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 coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 [DATE] 18.1.22 [SIGNED BY CORONER] 2
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.
Information Classification: CONTROLLED
2nd Floor
2 Redmond Place
London
E20 1JQ
United Kingdom
18 March 2022
Andrew Cox
H.M. Coroner’s Office
The New Lodge
Newquay Rd
Penmount
Truro
Cornwall
TR4 9AA
Sent via email: cornwallcoroner@cornwall.gov.uk
Dear Mr Cox,
I write in response to your regulation 28 report of 18 January 2022 regarding the very sad
death of Coco Bradford. I would like to offer my sincere condolences to Coco’s family.
Your report, which has been reviewed by our internal patient safety team and chief medical
officer, states that the NICE guideline on the diagnosis and management of diarrhoea and
vomiting caused by gastroenteritis in under 5s [CG84] is not in line with the UK Resuscitation
Council’s 2021 guideline on paediatric advanced life support. Having reviewed the guidance,
we agree that the volume of fluid bolus does not align and as a result of this being
highlighted, we have also looked at our other guidance of relevance.
It is important to note that CG84 covers diagnosing, managing and referring infants and
young children younger than 5 years who present with acute diarrhoea with or without
vomiting. We have not published guidance on this topic for people aged 5 years and older.
However, we do have separate guidance that does cover children over 5 years of age on the
recognition, diagnosis and early management of sepsis [NG51 from 2017] and guidance
[NG29 from 2020] covering intravenous fluid replacement for children in hospital. All of this
guidance has been reviewed considering your report, for their alignment to the 2021 UK
Resuscitation council guidance.
In light of our initial review, your report has now been forwarded to our guideline surveillance
team who will review the UK Resuscitation Council’s 2021 guideline and consider if CG84
and other related NICE guidance need to be updated.
Finally, you also note the difficulty of treating a child with bacterial gastroenteritis who is
suspected to have concomitant sepsis and ask if guidance on ‘how to weigh the balance of
risk and who to involve in the decision-making process’ would be useful. Reflecting on the
specific issue raised in your report, that ‘the administration of antibiotics may precipitate or
worsen [haemolytic uraemic syndrome] and, if the child is subsequently found not to have
sepsis, may inadvertently cause harm’, we consider this to be a matter of clinical judgement
and not something that could be addressed by a guideline. Haemolytic uraemic syndrome is
Information Classification: CONTROLLED
however considered in the NICE Clinical Knowledge summary on gastroenteritis last revised
in August 2020.
Please do let me know if you require any further information and again, I offer my sincerest
condolences to Coco's family.
Yours sincerely,
Dr
Chief executive
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