Lewys Ryan Aidan CRAWFORD · Prevention of Future Deaths report

On 28th March 2019 I commenced an investigation into the death of Lewys Ryan Aidan CRAWFORD. The investigation concluded at the end of the inquest 14th February 2020. The conclusion of the inquest was Natural causes contributed to by neglect - gross failure up to and including 11:30pm on 21/03/2019.

Cause of death recorded as:-

1a. Meningococcal Septicaemia (Group B)

These were recorded as :-

It is likely Lewys was in early stages of Meningococcal disease when he was admitted to A&E at University Hospital of Wales, Cardiff on 21/03/2019 at 08:15pm. There were multiple opportunities missed before 11:30pm to identify Lewys as having one or more high risk factors for Sepsis. There was a failure to treat Lewys with antibiotics before 11:30pm and this significantly contributed to Lewys' death on 22/03/2019 by which time he had been transferred to the Paediatric Critical Care Unit.

The Inquest focused upon numerous issues. However, at its core was the appropriateness, timeliness, and causative significance of the care provided to Lewys following his presentation to A & E. Particularly in the early stages of his treatment between triage and around 11.30pm on 21.3.19

(1) A potential deficiency in the knowledge and understanding of A & E Consultants coving in the paediatric A & E Department (whilst there is no on site consultant in paediatric emergency medicine) in the identification/diagnosis of sepsis in babies and very young children. Whilst it is appreciated that the quest to recruit further consultants in paediatric emergency medicine to provide more comprehensive cover in the Department continues, until such time as a sufficient complement is in place, and A & E Consultants provide some of the cover, the Health Board must ensure that those that do, are urgently and adequately trained to a competent standard to deliver the care required. It cannot be simply left to the individual consultants to determine their own requirements in this regard. As their employers, the Health Board, has an overarching obligation to ensure that competent staff are employed and to maintain high professional standards.

(2) There needs to be a greater understanding of, and reference to the NICE Sepsis risk stratification tool: children aged under 5 years in hospital by Clinicians and Nurses in both the A & E & Paediatric depts. Whilst it is appreciated that the finalisation of a bespoke sepsis tool, based upon the UK Sepsis Trust’s Tools and Pathways is awaited, until such time as its adopted, the Health Board needs to address apparent lapses in the understanding of what is required upon diagnosis of a potentially septic baby/child, particularly in the period between triage and admission to the ward. Specifically, the importance of stabilising the patient prior to transfer by completing a full septic screen. Furthermore, the Inquest highlighted gaps in the understanding and knowledge of agency nurses as to the septic screen and the steps to be followed. The Health Board needs a clear policy (and to ensure this is implemented & followed) to ensure that agency nurses are up to date with their training and understanding in this area of practice.

(3) Guidance and instruction to both clinicians and nurses as to the appropriate use (and recording) of terminology should be considered in suspected sepsis patients. There was a degree of confusion in both the A & E & Paediatric Departments caused by the interchangeable use of sepsis and bacterial infection as to what treatment should be initiated/progressed depending on which description was used. If sepsis is suspected, that clear and continuing reference ought to be maintained, if, and until it is superseded by an alternative diagnosis.

(4) In suspected sepsis patients, particularly babies, guidance and instruction needs to be emphasised to clinicians & nurses as to alternative methods of administration of antibiotics. Evidence at Inquest demonstrated that there were failures to consider alternatives to cannulation for IV antibiotics, such as intra-muscularly or intra-osseously.