Marc Jason Stephen Poole (known as MJ) was 6 years of age. He lived at home with his parents and siblings. At the age of 2 MJ was diagnosed with Autism Spectrum Disorder, low functioning with a learning disability.
On 16 May 2015 whilst out with his sessional worker MJ complained of a headache and had vomited. He returned home and appeared pale and lethargic.
He was taken to Doncaster Royal Infirmary and was later admitted at 19.30. It was suspected that MJ had an infection but the source of this was unknown. The management plan was to obtain a urine sample, chest x-ray and bloods and to thereafter commence IV fluids and antibiotics.
Bloods were taken on 17 May and revealing an elevated CRP. After some delay a urine sample was obtained and antibiotics later administered. A mottled rash appeared a little before 16:00 hours which worsened and his extremities became white.
Bloods at 18:30 hours were telephoned through at 18:50 hours. These results indicated a massively increased CRP. It was also identified that MJ was underscored on the PAWs score chart (an assessment tool in checking the condition of a sick child).
There were also incomplete observation checks. Despite MJ’s worsening condition and the continued appearance of a mottled rash. Observations taken at 20.00 only recorded his temperature.
MJ became increasingly agitated and was assessed just after 22:00 hours by this time MJ had collapsed, A crash call was made and Embrace were contacted.
MJ was transferred to Sheffield Childrens Hospital. Sadly, despite all intervention, he passed away on 18 May. Due to the nature of MJ’s treatment, an Inquest was held into the circumstances relating to his death; at Doncaster Coroners Court.
At the conclusion of the Inquest, the Coroner, Ms Nicola Mundy, identified a number of areas of cause for concern relating to unreliable PAWs scoring and recording of the observations.
She found that it was clear that MJ was very unwell on 16 May. There was a suspicion of infection. Once blood was taken, antibiotics should have been given.
Ms Mundy found that if antibiotics had been started in the evening of 16 May, on the balance of probabilities, MJ would have survived.
It was concluded on the balance of probabilities that the cause of death was as follows - 1a. septicaemia, 1b. pneumococcal septicaemia, c. sinusitis.
Regulation 28 report to prevent future deaths
At the conclusion of the Inquest, the Coroner has the power to write a report if there is a risk of other deaths occurring in similar circumstances. In this case, the Coroner directed that she would prepare such a report to the Chief Executive of Doncaster and Bassetlaw Hospitals NHS Foundation Trust, with a copy to NHS England.
She identified the following five areas of concern -
Poor communication on a number of levels
The Coroner found that there was insufficient discussion with the parents regarding MJ’s history. She believed there was insufficient weight attached to the information they did provide at the time of admission and later on. There was an absence of protocols or guidance as to how best to communicate with children with disabilities such as Autism, as MJ had. She also identified that communication between staff was poor, from health care assistants and nurses, from nurses to doctors and between junior doctors and senior doctors. There was ineffective communication in respect of blood results which had been phoned through to the ward but not immediately passed on to those who needed to undertake assessment.
PAWS – observation chart
The Coroner found that these were poorly completed. She noted that there were occasions where incorrect scoring had been documented, understating MJ’s condition at that time. She recommended further training to ensure accurate completion of this form and accurate scoring.
Sepsis and Paediatric
The Coroner stated that it was clear that consideration should be given to developing a protocol and guidance for those treating children. A Paediatric screening tool should be available. She said there needed to be clearer explanations of the terms: septic, sepsis, septic shock, septicaemia, bacteraemia. She found that these terms were used interchangeably. Staff needed more guidance as to what they should be looking out for and how these might be responded to.
Dissemination of key information and medical updates
The Coroner found there needed to be a review of the systems currently in place for disseminating information.
Poor record keeping
The Coroner found that there were a number of occasions where no record was made at all. It is of course imperative that clear records are made of significant events or developments in a persons medical treatment.
The Trust have responded to the recommendation.
Amongst others, over the identification of sepsis, the Trust have acknowledged the shortcomings. They have confirmed that since the Inquest, they have worked rapidly to introduce an identification tool based on the UK Sepsis Trust tool. A tool has been implemented and disseminated in all clinical areas. Further training on sepsis in children has also been provided.
UK Sepsis Trust – Clinical Toolkits
Since the Inquest, there has been a major step forward in the early recognition of sepsis in the development of clinical toolkits by the UK Sepsis Trust. Toolkits have been developed in a clear format for clinicians to identify the early signs and symptoms of sepsis, depending upon the age of the patient. These guidelines support the NICE (National Institute of Health and Care Excellence) clinical guideline of sepsis. Within this guidance, NICE advise all doctors to consider the possibility of sepsis in all patients who have symptoms of infection.
This is a major step forward in the treatment of sepsis and it hoped that deaths such as MJ’s can be avoided in the future.