Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, written 22 Jan 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 Jan 2018 |
|---|---|
| Deceased | Caliel Smith-Kwami |
| Coroner | Nadia Persaud |
| Coroner area | London (East) |
| 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.
Eastern Area of Greater London Coroners
MISS N PERSAUD
SENIOR CORONER
Walthamstow Coroner's Court Queens Road Walthamstow E17 8QP
Telephone 020 8496 5000 Email coroners@walthamforest.gov.uk
REF:4597
22nd January 2018
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO: Dr Alistair Chesser, Chief Medical Officer, Barts Health NHS Trust
sl CORONER
lam Miss N Persaud Senior Coroner for Eastern Area of Greater 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.
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 28/11/2016 | commenced an investigation into the death of Caliel Arlington SMITH-KWAMI. The
investigation concluded at the end of the inquest 19th January 2018. The conclusion of the inquest was a
narrative conclusion:
Caliel Arlington Smith-Kwami suffered from a profound hypoglycaemic episode around 28 hours following
his birth. As a result of this, it is likely that he sustained a hypoglycaemic injury to his brain. He was
admitted to hospital and tests were undertaken, in hospital, to determine the cause of the
hypoglycaemia. Caliel was discharged from hospital before key test results were obtained. The results of
these tests, when later received, revealed a likely diagnosis of hyperinsulinism. These results should have
been chased and received before discharge. Had they been received it is likely that Caliel would have
undergone further investigation, monitoring and treatment by a specialist team.
The health visitor attending Caliel on 4 August 2016 did not make contact with the NICU or the
community midwives. There was a missed opportunity for the health visitor to highlight the outstanding
test results and to ensure the involvement of the community midwives.
Caliel did not undergo any specialist investigation, monitoring or treatment. He passed away on the 17
August 2016 from persistent neonatal hyperinsulinaemic hypoglycaemia. Had Caliel been referred to the
specialist team, as he should have been, on the balance of probabilities his death at that time would have
been avoided.
4 CIRCUMSTANCES OF THE DEATH
See narrative conclusion.
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. —
(1) The insulin results were delayed, due to a fault with the analyser. Clinicians were not notified by the
lab, that the analyser was not functioning. No alert was sent out. Contingency plans could have been
put in place, to ensure that alternative arrangements were made for the test to be analysed before Caliel
was discharged from hospital. The independent expert was critical of the lab’s failure to notify clinicians.
(2)Test results do not appear to have been chased up before Caliel’s discharge from hospital. It was
unclear from the evidence who had the responsibility for chasing up test results prior to discharge.
(3)The results of the amino acid profile, which raised the possibility of hyperinsulinism were sent through
to the electronic record system on the 9 August 2016. It does not appear that any clinician was aware of
this result prior to Caliel’s death. The Consultant in Charge of Caliel’s care stated that there is no system
in place with the electronic record system for highlighting to clinical staff that results are ready. He
stated that when paper records were in place, clinicians would result the paper result, but this
notification has now been lost.
(4) The independent expert stated that in the absence of the insulin and amino acid profile results, a
ketone test might have assisted with the diagnosis. He stated that ketone tests can be obtained at the
bedside and that this has recently been introduced within his Trust. No witness at the inquest was able
to confirm whether the bedside ketone test was available within Barts Health NHS Trust.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | 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 20
March 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 _
HE Caliel’s mother) and HE (00 behalf of East London Foundation Trust). | have also sent it to
the CQC and to Mr Matthew Cole (Director of Public Health), who may find it useful or of interest.
| 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.
22/01/2018
signature S03 {
Miss N Persaud Senior Coroner Eastern Area of Greater London
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