Organisation we investigated: James Paget University Hospitals NHS Foundation Trust
Date investigation closed: 28 August 2019
Miss K complained about the care and treatment that her son, Baby K, received at the Trust in November 2015. She said that the Trust failed to act following various checks on Baby K, and it failed to escalate his care in line with the seriousness of his condition and he died as a result.
Miss K also complained about the Trust’s handling of her complaint.
What we found
We found that the Trust failed to:
- act on the results of the ECG and chest X-ray
- consider Baby K’s history and symptoms
- ask for input from specialist staff
- escalate his care when his condition was getting worse.
If these failings had not occurred, it is likely that the Trust would have recognised that Baby K had a problem with his heart. In these circumstances he would have received the correct treatment instead of being treated for suspected pneumonia. We found that on the balance of probabilities, his cardiac arrest would not have occurred, and it is more likely than not that his death would have been avoided.
We also found that the Trust was not open and accountable in its handling of Miss K’s complaint, as it failed to acknowledge and apologise for its mistakes in a timely manner. It also failed to signpost Miss K to us at the right time and in the right way.
Baby K experienced weight loss following gastroenteritis so his GP referred him to the Trust on 2 November. The GP referral noted that the area of his stomach just below his ribs was drawn inwards, but this was not recorded in his medical records at the Trust. Staff carried out blood and urine tests and an appointment was made with a dietitian for four weeks later.
On 12 November Baby K was taken by ambulance to the emergency department of the Trust after he vomited and became floppy. Trust staff examined Baby K and he was given a Paediatric Early Warning Score (PEWS) of four because he had a fast heart rate and was breathing very fast. A chest X-ray showed that his right lung had changed and part of his left lung had filled with fluid. Staff suspected that he had sepsis and possibly aspiration pneumonia, which occurs when food or liquid is breathed into the lungs or airway leading to the lungs. Staff gave him oxygen, antibiotics and fluids.
Baby K was transferred to a paediatric ward and his PEWS increased to five, which meant that his condition was getting worse. An Electrocardiogram (ECG), which measures cardiac activity, showed abnormalities including a fast heart rate. Staff observed Baby K hourly and on 13 November, they inserted a tube down his throat to help his breathing. Soon after this, Baby K’s heart stopped and staff began cardiopulmonary resuscitation (CRP) which they continued for almost one hour, but Baby K sadly died.
A postmortem showed that Baby K had a heart abnormality which had caused damage to his heart.
Putting it right
We recommended that the Trust write to Miss K to acknowledge the failings we identified and apologise for the impact they have had. The Trust should produce an action plan to explain how it will ensure that similar failings do not occur in the future. We also recommended that the Trust pay Miss K £15,000 in recognition of the injustice suffered.