Emmanuel Tobiloba Akinmuyiwa · Prevention of Future Deaths report

On 18/02/13 I commenced an investigation into the death of Emmanuel Tobiloba Akinmuyiwa. The investigation concluded at the end of the inquest on 12 September 2014. The conclusion of the inquest was that the deceased died from 1a. Cardiac failure due to 1b. Severe anaemia due to 1c sickle cell disease. I recorded a narrative conclusion as follows:

Emmanuel died on the 11th February 2013 as a result of severe anaemia caused by a sickle cell crisis. During his admission there was a gross failure to check his HB on 10/02/13 and a failure to provide an earlier blood transfusion. On balance earlier monitoring of his haemoglobin and an earlier blood transfusion would have avoided his death. His death was contributed to by neglect.

Emmanuel was a 7 year old boy who suffered from sickle cell disease. On 08/02/13 he was referred to Birmingham Heartlands Hospital and found to have a HB of 5.7. He was diagnosed as being in sickle cell crisis. On 09/02/14 his HB was 5. Instructions were left that he should have a further blood test taken on 10/02/13. A junior doctor decided not to undertake that test as Emmanuel looked clinically well. On 11/02/13 his HB was checked. The result was available at 4pm and confirmed a level of 2.8. At 20.30 he was given a transfusion. At 21.50 he got up to toilet and collapsed. He could not be resuscitated and died.

Evidence at the inquest confirmed that there needed to be a clear protocol in the West Midlands for the management of patients with Sickle cell disease. Ordinarily they are managed at Birmingham Children's hospital. In this case as Emmanuel was admitted to Heartlands hospital various telephone calls were made to Birmingham Children's hospital. It was acknowledged in an internal investigation by Birmingham Heartlands hospital that staff had a lack of knowledge and appreciation for the signs and symptoms of a sickle cell crisis and what treatment was necessary. I was informed at the inquest that clinicians would prefer a hub and spoke approach to treatment of sickle cell disease with clear guidelines and protocols for how and where patients should be treated. I was informed that this had not happened to date due to the lack of funding available to liaise with all local hospitals and produce and put in place such protocol and guidance. A lack of guidelines and protocols for the West Midlands means future patients are at risk of death.