Adam Alexander Bojelian · Prevention of Future Deaths report

On 27th March 2015 an investigation was commenced into the death of Adam Alexander Bojelian, aged 15. The investigation concluded at the end of the Inquest on 3rd February 2020. The conclusion of the Inquest was natural causes.

The medical cause of death was:

1a Multiorgan failure
b Multiagent infection: Enterococcus faecium, Serratia marcescens and Candida sp
c Quadriplegic cerebral palsy

Adam Alexander Bojelian suffered a severe birth injury and was profoundly disabled due to quadriplegic cerebral palsy, epilepsy, chronic lung disease and other conditions.

He was admitted into hospital in September 2013 and remained in hospital for some 17 months until taken to a hospice on the eve of his death on 24/03/15.

His parents were concerned at the quality of his care in the hospital and pressed for him to be admitted to a paediatric intensive care unit (PICU). The treating doctors did not consider this was required until 25/02/15, when he was transferred to PICU.

(1) Training Records for Nurses.
The evidence revealed that in 2015, the Trust did not hold records of the training received by individual nurses. Instead, it was left to each individual nurse to maintain their own training records.

The concern arising from this is that, without accurate records, a Trust cannot be sure a particular nurse has the required skills and competence to carry out a particular task. Instances of this revealed at the Inquest was whether nurses on ward 40 at LGI had received training in relation to Bair Huggers or BiPAP ventilation equipment used in the care of critically ill children.

(2) Formal Written Care Plans
The evidence taken at the inquest revealed that despite the complex medical needs of this child, no formal written care plan was created for the period he was in hospital, from September 2013 to January 2015 (15 months). It was assumed all the clinicians involved would glean sufficient information from a review of his notes.

The absence of a plan meant that aspects of his treatment were not exposed as being controversial (and disputed by his parents). An example of this related to hydrocortisone therapy.

In complex cases, a comprehensive care plan would provide both parents and clinicians with a basis upon which to obtain a second opinion from an independent source in the event of a dispute, as occurred repeatedly in this case.