Jack Dulson · Prevention of Future Deaths report

On 12/05/14 I commenced an investigation into the death of Jack Dulson aged 9 years. The investigation concluded at the end of the inquest on 05/08/14. The conclusion of the inquest was that Jack died from natural causes due to pericarditis.

Jack had been a previously fit and well young boy. He became lethargic and developed knee pain and a temperature resulting in his parents taking him to City Hospital Stoke on Trent on 07/03/14. He was diagnosed with a viral illness and discharged home. He appeared to make a recovery until the 25/03/14. At that time he was lethargic and couldn't swallow. He was seen by ████████ his GP. A blood test was arranged. This was undertaken on 27/03/14 at City Hospital. The results were available at the GP surgery on 27/03/14. They confirmed a CRP of 169 (very high) and indicating infection) and anaemia. The results were not reviewed by ████████ until the family requested an appointment which took place at 17.50 on 28/03/14. At that time Jack was seriously ill and was admitted as an emergency to City Hospital where he was diagnosed with pericarditis causing a pericardial effusion. He was transferred to Birmingham Children's Hospital on 29/03/14. He had insertion of a pericardial drain on 31/03/14. He appeared to be making progress until he suffered a sudden cardiac arrest on 03/04/14. He could not be resuscitated and passed away at 22.45.

The evidence at the inquest confirmed that earlier treatment and diagnosis would not have made a difference to the outcome.

(1) The GP practice had no system in place to review abnormal blood test results when they were received and to then review the patient and provide treatment.

(2) The abnormal blood tests were only reviewed when the family arranged and insisted on an appointment – this was over 24 hours after the tests results were available.