A fatal accident inquiry finds that the death of a three-year-old boy at the Royal Hospital for Children at the Queen Elizabeth University Hospital Campus could have been avoided.
A three-year-old boy died at the Royal Hospital for Children at the Queen Elizabeth University Hospital Campus, Glasgow, on 20 November 2019. Sheriff Thomas Millar at Glasgow Sheriff Court concluded that the boy’s death might realistically have been avoided had an abnormal blood test result been identified and acted upon earlier.
The determination found defects in systems of working, including failures to follow relevant clinical guidance and the boy’s care plan, missed blood test results, and the absence of a post-clinic multidisciplinary review.
“The death of [the boy] occurred in circumstances giving rise to significant public concern and as such a discretionary Fatal Accident Inquiry (FAI) was instructed,” said procurator fiscal Andy Shanks for the Crown Office and Procurator Fiscal Service.
“The sheriff’s determination is detailed and notes a reasonable precaution that could have been taken to avoid [his] death. The FAI followed a thorough and comprehensive investigation by the procurator fiscal, who ensured that the full facts and circumstances of Archie’s death were presented in evidence,” he added.
Failure to follow appropriate guidelines
The inquiry found that there was a failure to follow appropriate guidelines and an anticipatory care plan in place for the boy, in terms of which an infection specialist should have been consulted and/or blood cultures ordered where there was a possibility of line or other infection, as indicated by the regular higher-than-normal amount of C-reactive protein (CRP) in the blood.
There was a failure to note the boy’s raised CRP level of 98mg/L on 5 November in his discharge letter and thereafter at a multi-disciplinary team (MDT) meeting, which normally followed an admission but did not take place and was not rescheduled.
There are other factors that are relevant to the circumstances of the death, but which did not contribute to that outcome. On 19 November 2019, the boy was seen at a renal outpatient clinic. He was noted to have a loud systolic heart murmur. His doctor correctly suspected bacterial endocarditis, ordered blood cultures and identified the need for an ECG and echocardiogram.
She requested his admittance to the renal ward for a blood transfusion and for those tests. Due to seasonal demand, no place in the ward was available until 1915 hours, some hours later. This delayed appropriate monitoring, triage and clinical care.
“His deterioration in the early hours of 20 November could not reasonably have been anticipated, and these delays, although regrettable, did not contribute to the outcome,” the inquiry concluded.
Death was caused by subacute bacterial endocarditis with extensive associated myocardial infarction in a child with chronic renal failure due to congenital nephrotic syndrome.
