Article

From the TS&P casebook - K

K was born in December 2004 at a DGH in Kent at 29 weeks gestation. She was born with the rare condition of gastroschisis where the baby’s intestines are on the outside of the abdominal wall. She was transferred to a London teaching hospital and underwent surgery to return her intestines to the abdomen. Numerous post-operative complications meant that K’s intestines did not function properly so she had to be fed intravenously. In December 2005 it was planned that K would have further surgery by way of a Nissen fundoplication and gastrostomy to help with her nutrition. K had spent all her life in hospital and it was hoped that following this surgery she would be well enough to go home. For the surgery K was to be transferred to another London teaching hospital. The transferring hospital advised that K would need a platelet transfusion immediately before the surgery. Due to the uncertainty of a bed being available, K was not transferred to the receiving hospital until late evening on the 14 December 2005 and due to the late hour, she was not seen by either her surgeon or consultant paediatrician. The SHO on the paediatric ward that night requested platelets from the laboratory to be available in the morning. K’s surgery was planned for 10.00 am. She was prepared for theatre by a paediatric SHO, Dr A. However, this doctor was new to her post, had little experience of paediatrics and even less of paediatric blood transfusions. She sought advice about the amount of platelets to be transfused but was unable to speak to surgeon who was already in theatre, or a consultant paediatrician. She contacted the haematology registrar to ask for advice. She was told that K should be given “one pool” of platelets over half an hour. This is what she wrote on the drug chart. “One pool” of platelets is about 300 ml volume. The nurse who came to set up the transfusion was concerned that 300 ml was a large volume to give to a small, sick child over half an hour. She voiced her concerns to Dr A who asked her to seek advice from the paediatric registrar. In evidence, he said that he had advised that K be given 15 ml per kilogram over half an hour. The nurse however was adamant that he told her to give 50 ml per kilogram over half an hour which would, in volume terms, amount to 300 ml i.e. the whole pool of platelets. Transfusion was commenced at 9.45 am and at 10.00 am K collapsed with acute respiratory failure and pulmonary haemorrhage leading to cardiac arrest. K was resuscitated and taken to the paediatric ICU but her condition deteriorated and she died two days later. The hospital held a serious untoward incident inquiry. It was accepted that K had died as result of being given excessive platelets and this resulted from significant system failures including poor communication and poor compliance to hospital procedures.

There was an inquest into K’s death, at which we were instructed to represent the family. Legal aid funding was refused on the basis that we should await the outcome of the inquest, as this might mean that further investigation was not required. We therefore entered into a conditional fee agreement and provided representation at the inquest. The coroner returned a verdict of accidental death due to K being given too large a volume of platelets over too short a time. Within a few weeks of the inquest we
were able to settle K’s mother’s claim for bereavement damages and funeral expenses. The trust has now confirmed that a number of measures have been put in place as a result of lessons learned from K’s tragic death. These include:

= A consultant to be identified as responsible for the care of a patient transferred from another hospital.
= Implementation of written clinical guidelines for paediatric blood transfusions.
= All SHOs in paediatrics to attend a statutory paediatric induction course which will include training in prescribing blood platelets.
= Staff encouraged to escalate concerns regarding a patient’s care to the highest level of authority.
= Ward managers to ensure appropriate allocation of patients to nursing staff.
= Improved record keeping.

The case shows that medical accidents can lead to major improvements in care particularly where errors have been admitted and there has been an inquest. Unfortunately it is very rare for incidents to lead to improved procedures in the more common situation where liability is denied.

For further enquiries please contact Graham Bell (view full profile) on 01892 701358 or email graham.bell@ts-p.co.uk.

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