Amelia Alexandra Anuszka RIDOUT · Prevention of Future Deaths report

On 27 June 2022 I commenced an investigation into the death of Amelia Alexandra Anuszka RIDOUT aged 6. The investigation concluded at the end of the inquest on 21 March 2024. The conclusion of the inquest was that:

Amelia Ridout underwent a bilateral bone marrow aspirate and trephine procedure at Addenbrookes Hospital on 16th June 2022 following a diagnosis of pancytopenia. A bilateral bone marrow aspirate and trephine procedure was carried out by a Paediatric Oncology Specialist Doctor whose understanding at the time was that Amelia Ridout’s differential diagnosis still included the possibility of a solid cancer which would require a bilateral bone marrow aspirate and trephine procedure to ensure accurate diagnosis. The Senior Clinical Fellow in Paediatric Haematology who had asked for the bone marrow aspirate and trephine procedure to proceed had not specified whether the bone marrow aspirate and trephine procedure was to be a unilateral or bilateral procedure.
The bone marrow aspirate and trephine procedure was carried out under general anaesthetic with a Consultant Anaesthetist in attendance.
Amelia Ridout was positioned on her left side for the bone marrow aspirate and trephine procedure. The right sided bone marrow aspirate and trephine procedure was completed. Following the completion of the left sided bone marrow aspirate and trephine procedure the Paediatric Oncology Specialty Doctor carrying out the bone marrow aspirate and trephine procedure noted a spurt of blood on removal of the trephine needle and queried the sample extracted. The supervising Consultant Haematologist was called in to review and confirmed that there was no signs to raise concern and that the bone marrow aspirate and trephine procedure should be concluded. Amelia Ridout remained positioned on her left side for the bone marrow aspirate and trephine procedure in line with the training and practise adopted by the Paediatric Oncology Specialist Doctor.
Shortly after the conclusion of the left sided bone marrow aspirate and trephine procedure at 11.32am, Amelia Ridout started to decompensate and rapidly went into Pulseless Electrical Activity arrest (PEA arrest). Full Advanced Paediatric Life Saving procedures were commenced. The paediatric resuscitation team attended promptly, the on call Paediatric Surgeon was alerted and it was rapidly established and agreed based on Amelia Ridout’s differential diagnosis that Amelia Ridout was suffering an internal bleed as a result of the bone marrow aspirate and trephine procedure which needed to be dealt with through surgical intervention as a priority.
The clinical team arranged for an operating theatre to be made available as a matter of emergency, a vascular surgeon was requested to attend and interventional radiological solutions were explored and excluded. AR’s resuscitation and stabilisation, continued and she was transferred to an operating theatre at 13.05.
Amelia Ridout was prepared for an emergency laparotomy by the Anaesthetic team. Central Venous lines and arterial access were sited by the Anaesthetic team,to allow them the ability to provide lifesaving resuscitation to Amelia Ridout intra-operatively. On arrival at the Operating Theatre, Amelia Ridout was relatively stable as a result of the continued resuscitation efforts. The clinical team managing the emergency laparotomy anticipated that invasive surgery could lead to a rapid destabilisation in Amelia Ridout’s condition.
Shortly after the start of Amelia Ridout’s surgery, Amelia Ridout went into PEA arrest and needed chest compressions. The surgical team continued to treat Amelia Ridout’s internal injury and identified a defect in the anterior arterial wall of the external iliac artery, the appearances of which were consistent with the anticipated needle injury caused by the bone marrow aspirate and trephine procedure. Amelia Ridout’s condition continued to deteriorate despite continued resuscitation efforts. The clinical team took the decision that continued efforts would be futile and Amelia Ridout was declared deceased.

6-year-old girl with suspected aplastic anaemia attended the paediatric day unit on 16th June for a minor surgical procedure under general anaesthetic (a bone marrow aspirate and trephine). During the procedure, the trephine needle accidentally penetrated through the pelvic bone and pierced the iliac vessels causing massive, catastrophic bleeding internally. Following prolonged resuscitation, he was transferred to the theatre under paediatric and vascular surgical teams, but the bleeding could not be stopped, and after further prolonged resuscitation attempts, she died in theatre.

To consider the development and publication of a national guidelines and standard operating procedure for the carrying out of Bone Marrow Aspirate (BMA) and trephine biopsy to include recommended methodology.

To consider the development of a data base to record these procedures and their outcomes.