Rasharn Kirk WILLIAMS · Prevention of Future Deaths report

On 29 October 2014, one of my assistant coroners, Richard Brittain, commenced an investigation into the death of Rasharn Williams, aged 9 years.

The investigation concluded at the end of the inquest on 24 April 2015, when I made a determination that Rasharn died from natural causes.

His medical cause of death was:

1a hypoxia
1b generalised seizure
1c univentricular cyanotic congenital heart disease
with pulmonary hypertension

Rasharn’s cardiologist had not expected him to live to adulthood, but had not expected him to die this quickly. He was a little boy who enjoyed life and engaged with it fully, despite his heart problem. Upon the direction of his doctors and with the agreement of his mother, Rasharn was allowed to participate in school activities, but then to sit out when he felt tired.

On 23 October 2014, he was having fun at a school disco when he became fatigued and sat down. He was noticed by a teacher who approached him. He began to cry and was breathless and distressed, so she took him into the school office to sit down. This was at approximately 4.30pm. Rasharn’s mother was telephoned and asked to come in to school.

After a while, Rasharn appeared to improve a little, and the teacher left him with two members of the administrative staff. One of these was a permanent member who was also a first aider, and one was a more junior, temporary member who was not a first aider but, coincidentally, had looked after a little boy with epilepsy in the past.

Approximately seventeen minutes after being brought in to the office, at around 4.47pm, Rasharn deteriorated and became somewhat absent. The junior member of staff suspected him to be having a seizure and asked if an ambulance should be called. The first aider did not think this was a seizure and so formed the view that an ambulance should not be called.

Despite the fact that Rasharn had never suffered a seizure before, and was not thought to be particularly at risk of seizures, the likelihood is that this was a seizure from which he never really recovered, and that he later had more seizure activity.

His mother arrived three minutes after the seizure began, at around 4.50pm. Four minutes after that, at 4.54pm, the first aider called an ambulance. The ambulance arrived at 5.03pm. While Rasharn was in the back of the ambulance but still on the premises, at 5.14pm, he suffered a cardiac arrest. He was treated and transferred to hospital, arriving at 5.19pm.

Rasharn was treated aggressively in hospital, but died later that evening. It is unclear whether earlier medical intervention could have changed the outcome on this particular occasion.

1. Whilst staff at the school were clear that they should call an ambulance in the case of an emergency, and I heard evidence from the first aider that she would have called an ambulance immediately if she had thought Rasharn was having a seizure, Rasharn’s care plan was not wholly clear on this point.

The plan described breathlessness as an emergency. I appreciate that this may have had its origin with Rasharn’s treating clinicians. However, his exercise tolerance was reducing all the time and so breathlessness was, to a degree, a feature of his condition. Extreme breathlessness coupled with low oxygen saturations would be a different matter, but this was not made clear in the plan.

This potential lack of clarity did not have an impact on the outcome in this particular situation, but it might in another. It seems that your care plans may benefit from some review to ensure that there is no ambiguity unwittingly created for those attempting to follow them.

2. I heard that some schools have notices with a child’s photograph and particular instructions regarding medical conditions, displayed in the staff room, office and medical room.

Rasharn did have such a notice, but it was only in the medical room, and was not actually displayed at the time of his death, because of transitional arrangements regarding a move of premises.

Again, this did not have an impact on the outcome for him, but might for another child.