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Investigation and inquest
On the 28th April 2020, I commenced an investigation into the death of Jacob Owczarek, aged eleven months. The investigation concluded at the end of the inquest on 30th April 2021. The conclusion of the inquest was a narrative as follows:
Jacob Owczarek presented to Bassetlaw Hospital Nottinghamshire, at the age of six months, very unwell. He had pyelonephritis, a serious kidney infection. This was treated, but he did not continue on an antibiotic to reduce the risk of further urinary infection after discharge, as was necessary, as the family did not understand this was required.
Follow up investigations to look for underlying abnormalities of the renal tract were performed. These scans showed obstruction of both ureters, the tubes that drain urine from both kidneys down to the bladder. The scan results were not reviewed in life, either at the time the scans were performed, nor when Jacob presented again at the age of ten months with a further kidney infection.
Jacob died at age eleven months from acute pyelonephritis. He also had evidence of chronic kidney scarring and infection, with severe urinary obstruction at the time of his death. Had the scans been reviewed in life it is likely on a balance of probability that he would have had treatment to relieve the obstructions, and would not have died.
His death was contributed to by Neglect.
Circumstances of the death
Jacob died from an acute kidney infection (pyelonephritis), a treatable condition. He had presented on two previous occasions unwell with sepsis from the urinary tract.
The seriousness of the infection on the second presentation, was not recognised, and he was allowed home. The investigations arranged to look for underlying structural abnormalities of the renal tract were not reviewed in life, and therefore Jacob was never referred for surgical treatment to relieve his obstructed renal tract.
There were systemic failings in his care, that remain in my view despite a Serious Incident Investigation undertaken, and action plan completed, by the Trust.
Coroner’s concerns
1. Continuing low compliance with the Paediatric sepsis screening tool
2. Lack of Named/Responsible Consultant review prior to a child’s discharge
3. No alert/review system for ICE results yet in place for all the Paediatric team
4. No current system for recording a discussion about a child, in the Radiology meetings (where important investigations are planned)
5. The risk of continuing Login issues when Locum doctors are working at the Trust
Information checked against the published report and official responses