Alfie Scambler-Holt · Prevention of Future Deaths report

On 5th June 2017 I commenced an investigation into the death of Alfie Scambler-Holt. The investigation concluded on the 8th May 2018 and the conclusion was one of;

Narrative: Died as a consequence of an overwhelming infection on a background of cerebral palsy.

The medical cause of death was; 1a Sepsis; 1b Respiratory Tract Infection; II Cerebral Palsy

Alfie Scambler-Holt had cerebral palsy and complex health needs as a result. On 3rd June 2017, just after 10.00, his mother went in to his bedroom and found he was very unwell. He had been well at 03.00. An ambulance was called and arrived within 10 minutes. Sepsis was suspected and he was transferred to Stepping Hill Hospital.

Stepping Hill Hospital were on standby for his arrival. He was treated for suspected sepsis. His PEWS score was 8. The initial intravenous access tissued out after 50ml of fluid had been administered. Repeated unsuccessful attempts over an hour were made to gain access before the doctors were successful and antibiotics could be administered. He was transferred to the Paediatric Unit. His care was supervised by the registrar. He was not seen by a consultant. His PEWS score was 6 and his blood gas results showed high lactate and sodium levels indicating kidney compromise. He was treated with fluid boluses being administered. Fluid output levels were monitored through nappies rather than catheterisation. His PEWS score dropped to 4. His blood gas results remained high.

A discussion with the on call consultant resulted in the agreement on the management plan. A consultant review in person was not carried out. At 20.00 on 3rd June 2017 his PEWS score rose to 6 and he was examined by the Registrar who prescribed a saline nebuliser in addition to the fluids prescribed. At 21.05, he suddenly stopped breathing. A prolonged attempt to resuscitate him was unsuccessful and he died at Stepping Hill Hospital on 3rd June 2018 from sepsis - 11 hours after his admission.

The inquest heard that since the death of Alfie Scambler -Holt the Trust had done a significant amount of work looking at PEWS scores and escalation processes. The Clinical Lead for Paediatrics told the inquest that one of the challenges was that there was no national PEWS scoring system. As a result there were different PEWS scoring systems in operation in different trusts. This meant that staff dealing with children and moving/rotating between Trusts would not necessarily be dealing with the same system and escalation processes.