NHS Highland S E Highland CHP

Transcription

1 NHS Highland S E Highland CHP Report of a Significant Event Review re a Child Held in 2011 INTRODUCTIONS This was the third investigation to take place regarding the untimely death of a child. It focussed on the primary care aspects. The other reviews centred around issues relating to the involvement of colleagues at a Hospital (where the patient died) and by the Scottish Ambulance Service (SAS). It more appropriate to a view of ascertaining what had occurred, what could be done better to mitigate any future similar events and lessons learnt from the overall review process. The review chair clarified which part of the process the Primary Care element of today s meeting was focussed on. This would be the situation prior to arrival at the Emergency Department. The Hospital had completed a review of events from when the child arrived at the hospital. The SAS had completed their internal review of their involvement, which was currently with the SAS Medical Director and Director of Service Delivery for signing off. It was reported that the SAS would share such report when it was available to do so. SUMMARY OF EVENTS 2011 The child was moderately asthmatic, on medication, who had a cardio-pulmonary arrest at home. During the course of the day at school, the child had notified the class teacher that they felt unwell and appropriate action was taken by the school to manage and monitor, bearing in mind the appropriate care plans in place to manage the condition. The school noted that there were no abnormal events with the asthma, the child had spoken with its mother at lunchtime, and the mother had arranged for a taxi to take the child home at the close of the normal school day. After climbing the stairs to the third floor flat where the child lived the child presented as being further unwell and the mother called the GP surgery and requested a home visit. Doctor 1 arrived, assessed the child and immediately requested a GP referral 999 ambulance. The child was treated at home, by Doctor 1 and SAS paramedics, where resuscitation procedures were undertaken. The patient was transferred to Hospital Accident & Emergency Department, where appropriate resuscitation continued, but no response was detected. CPR ceased at 18:36 on ****** The cause of death was respiratory failure. PATIENT SUMMARY Doctor 2 gave a summary of The child s medical history Child born st episode of bronchospasm. Prophylactic inhaler prescribed. 3 separate admissions to the Paediatric Ward with ongoing follow-up. Not unusually there were several instances of non-attendance at the Paediatric Clinic and reviews at the surgery, but these were followed up and attendances confirmed at further clincs/gp appointments. Doctor 2 noted that, on occasions, DNAs were due to an appointment at an alternative service clinic at around the same time No significant issues Preventative inhaler started again. Occasional attendance at surgery due to wheezing. Referred to Hospital. Consultant Paediatrician, was requested to provide a care management plan for the school GP consulted re: possible cat allergy Out of hours attendance and steroids given. DNAs at clinic, but followed up and attendance at further clinic Admission direct from clinic; this was a severe attack, but with a gradual onset. A detailed care management plan was noted in the discharge letter.

2 2009 School nurse had encouraged out-patient clinic attendance after DNA. Attended further clinic Stable and good. Before the final illness, an inhaler had been requested - on the request it was commented that the child was quite wheezy - so on the day assessment was arranged. The child was admitted to hospital and discharged with Prednisolone the next day (mild attack). Doctor 2 advised that use of inhalers was consistent, sometimes considered to be more on the side of over-use, rather than under use, but repeat prescriptions were always ordered. Doctor 2 could monitor use by the frequency of ordering of inhalers. Doctor 3 advised that this was a typical example of exacerbation of asthma due to allergies. Care plans in the hospital and within secondary care were consistent for the situation and well-established. Nurse 1 said that the appropriate care management plans were in place at the school. These had been drawn up in conjunction with hospital doctors. Nurse 1 had also worked with the family by phoning to remind them of The child s clinic appointments. Doctor 3 asked the Head Teacher if child was able to undertake the physical education lessons. Teacher 1 stated that child was advised to take 2 puffs before undertaking sport and that she was confident with using the inhaler. For the final admission, the Children s Services school notes suggest that a good care management plan was in place and was discharged to the care of the practice. EVENTS ON THE DAY OF THE INCIDENT Teacher 1 said that on the day of the incident, at the end of the morning check, The child had reported to the class teacher that the child felt unwell. It was suggested that the child could feel better once the child had eaten their lunch, which they proceeded to do, and to sit in the area by the offices allocated to pupils when they felt unwell. This was near the office where the first aider was located. The child was still feeling unwell and said that they felt like they were going to have an asthma attack. The child then asked the school if they could contact the mother, which they did and the child spoke to the mother. The mother did initially think that the child was putting it on and advised to rest in the area for sick children and walk home as per normal, with the sibling. The mother subsequently phoned the school to advise that a taxi had been for the children at 14:55 hours to take them home. Doctor 3 asked where the child s blue inhaler was kept. Teacher stated that it was kept in a poly pocket in a drawer by the teacher s desk and was readily available. Usually the child would ask for it. On 24 May, nurse 1 was in the school, having been asked to see other children; The child was not regarded as a priority that day. In fact, there were children at the school whose medical conditions were thought to be far worse than those of the child. Doctor 1 read out the following account of the events which was written using the contemporaneous clinical notes were made on the evening of the date of the incident. [Statement of Doctor 1] Ambulance service personnel 1 added the timings recorded by the SAS. After Doctor 1 s GP emergency call at 17:21 the first ambulance arrived at 17:30. There was some discussion as to whether the SAS had difficulty in locating the address. It was acknowledged that many home visiting professionals had difficulty locating addresses in the area. A call for backup was made and a second crew and a rapid response vehicle both arrived at the scene at 17:55. It was noted that the first crew were an air ambulance crew working on road ambulances that day. Discussion took place as to whether the air crew had the same level of expertise as road crews. Ambulance service personnel 2 advised that exactly the same equipment is used by both air and road crews. It was noted that air crews, at certain events, may have the greater depth of knowledge and experience than their road counterparts due to the nature of the events that they are called to attend. Page 2 of 5

3 Much robust discussion then took place around the placement or otherwise of the ET tube. Doctor 1 witnessed the insertion of an ET tube. Correct placement was reported to have been confirmed by direct vision at the time of insertion and Doctor 1 confirmed this by auditory examination of the chest. End tidal carbon dioxide monitoring, which has since started to be introduced in Highland was not at the time available to used. Doctor 1 reported that, probably due to the nature of the resuscitation procedures being undertaken, it was noted by those in attendance that the tube had become dislodged. It was then re-inserted and position confirmed, but Doctor 1 was unclear as to which paramedic undertook these tasks. Ambulance service personnel 2 stated that this re-entubation (first) had not come to light in the draft SAS investigation. Ambulance service personnel 2 undertook to review this evidence as there appeared to be a discrepancy. They were aware that the tube had been found to be dislodged when the child first arrived downstairs to the ambulance. It was believed that it could have become dislodged during the transfer down the stairs into the ambulance and the robust resuscitation attempts being made. The child was re-entubated (second) at that time. It was reported that on arrival the hospital the ET tube was recorded as being in the oesophagus. Doctor 3 gave a view that the events described were all taking place in a patient s compact home, where colleagues were working in an alien environment for undertaking resuscitation and would be very difficult and stressful for clinicians. The time line of the patient s deterioration had been extremely rapid and the succession of events led to a life threatening situation. After discussion with the hospital paediatricians, Doctor 1 realised the gravity of the situation. It could have been easier to carry out the procedures in an emergency room with the appropriate specialists in intensive medicine present, but the result may, sadly, have been the same. Doctor 3 continued by saying that that the critical time was 15:00-17:15 and considered whether anything else could have been done to alter the outcome. Doctor 3 did not believe so. It was a very atypical case, without any warning of any previous event. Doctor 3 considered that when the child climbed the stairs to their home, and collapsed on reaching it, the hypoxia started. Doctor 3 stated that it was the best care primary care clinicians could have provided here, in this situation, and complemented Doctor 1 for doing everything possible in the situation. The question was raised as to whether a 999 emergency call from the parents earlier in the afternoon could have had any bearing on the end result, but Doctor 3 did not know the answer to that question. It was very difficult to say if an earlier 999 call would have changed the situation. Nurse 1 added that the march of time had caught the mother unaware. Nurse 1 had seen the child s previous asthmatic episodes, but nothing like this was in their experience. The review chair suggested that this was not typical of The child s asthma, which was agreed. Doctor 2, in directing a question to Doctor 3, enquired about the difficulties of inserting ET tubes into children. Doctor 3 said that it would be particularly difficult if the child was agitated and struggling, and especially given the time span reported here. The Review Chair, in summarising the discussions relating to the ET tube, noted that there were two separate factors: the child s resistance due to hypoxia; whether chest compressions had dislodged the tube. Doctor 3 outlined the clinical factors due to movement of the tube and process of ventilation when vomiting had taken place. Doctor 3 had noted that the child vomited before the 1 st intubation took place. Doctor 3 asked Ambulance service colleagues whether there was anything in their draft report that conflicted with the events described today. Ambulance service personnel 2 responded by stating that it was just the matter of the ET tube, and, as mentioned earlier, SAS would review and report their findings in due course. Ambulance service personnel 2 then asked if mobile suction had been undertaken. Doctor 1 advised that it may have been done whilst Doctor 1 was absent collecting further equipment from the ambulance (it having been decided that it was more appropriate for SAS personnel to continue resuscitation). Page 3 of 5

4 WHAT WENT WELL: The Review Chair summarised the timeline of care management: There was a good care management plan in place at the school. Good care was taken by them on the day in question. The child s mother had spoken on the phone with her child at lunchtime and subsequently arranged for a taxi pick up from school. The call handling system at the general practice worked well. Triage by the on-call doctor (Doctor 1) was good. It was a textbook response to the call. The SAS performance for arrival and transfer times were within their usual limits, and considered to be good, given the time of day and heavy traffic involved. There was timely notification of the hospital of the impending arrival, allowing the appropriate team to be on stand-by. There was an appropriate notification, by the hospital, to the Procurator Fiscal. Doctor 1 had a long discussion with the child s mother. The school continues to support the mother. Doctor 2 had suggested to Doctor 1 to have some time off after the event, which Doctor 1 did. There was a support mechanism in place in their practice. WHAT MIGHT HAVE BEEN DONE BETTER: The Review Chair stated that there is, apparently, a discrepancy between Doctor 1 s account of ET tube management and the SAS draft report. Ambulance service personnel 2 referred to the 1 st tube in place and the resulting extubation. Doctor 1 was unable to tell at what time the 2 nd tube was inserted: Doctor 1 believed it was before the 2 nd ambulance crew arrived. Doctor 1 asked whether primary care colleagues should take oxygen out to calls in urban areas? After discussion with a considerable number of GPs with wide experience, it was not considered appropriate for urban GPs as the SAS were quickly available. Doctor 1 asked if they should have made the emergency 999 call immediately on arrival at the patient s home, before assessing the child? Doctor 3 offered further clinical opinions in that after initial examinations of episodes of paediatric asthma, an ambulance was not usually necessary. It was only after a further examination indicated the rapidity of the patient s deterioration that an ambulance was deemed to be necessary. Doctor 2 referred to information available to GPs. With the change of electronic record systems within the practice some pieces of information relating to older notes were not fully transferred to the new system. The Review Chair noted that as the detailed involvement of SAS colleagues had been documented in their report and also within the Raigmore Hospital review, it was not necessary to repeat here. Ambulance service personnel 2 referred to new procedures being put into place in emergency vehicles which now have the facility to monitor expired air of entubated patients, and also a new form of defibrillator was now available. The Review Chair asked education colleagues if they felt that anything further could have been done. Teacher 2 stated that, like Doctor 1, extreme management procedures could be put in place, but, again, this were not considered necessary for urban schools. An internal review of the situation had taken place and it was considered to be well managed by the school as it was a typical presentation of the child s condition. Sadly the emergency had occurred after the child left school for the day. Nurse 1 had also considered whether anything could have been done better by the school nursing service, but emphasised that the child had presented as being not particularly asthmatic that day. If the asthma had exacerbated, further measures and monitoring would have taken place. Doctor 3 wondered whether any education could be put in place for schools and parents of appropriate children so as to be able to deal with any potential for serious healthcare episodes. The Review Chair asked Doctor 1 if they had seen the child before during a consultation. Doctor 1 Page 4 of 5

5 saw the child once some time ago. The Review Chair outlined the route that would now be taken, i.e., that the draft report would be circulated to colleagues present for their comments. It was noted that the review had not considered the outcome of the Post Mortem. RECOMMENDATIONS The Review Chair considered that there were really not any recommendations regarding clinical care as all processes had worked well and appropriate procedures followed. Doctor 3 again offered the clinical view that the child s presentation of asthma during the school-day was not unusual, but changed to an atypical event very quickly following the child climbing the stairs to their home, resulting in the patient s deterioration very rapidly into a life threatening situation. This was managed in the best possible way, given the circumstances. Doctor 2 wondered whether there was the issue of when to call an ambulance? Ambulance service personnel 1 enquired whether the family had called an ambulance previously. Doctor 2 did not believe so, but the family may have done so for the out-of-hours service. As regards the investigation processes, the chair firmly believed that for any such future similar events, matters would be best served by having one timely inter-organisational review. SAS having reviewed their draft report should send it to the Board Medical Director. The Review Chair thanked colleagues for attending such a sensitive review and considered that it had been dealt with in an appropriate and respectful way. The meeting opened at 09:20 and closed at 11:05. Page 5 of 5