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Investigation and inquest
On 8th December 2021, this court commenced an investigation into the death of Shahan Abu Aman. The investigation concluded at the end of the inquest held on 31st August 2022. I made a determination of a narrative conclusion incorporating a finding of neglect;
“Shahan Abu Aman died in hospital on the morning of 8th December 2021.
Aman had attended the same hospital on the previous evening, 7 December 2021.
A lack of communication between the nursing and medical team led to an inappropriate discharge from hospital, had Aman remained in hospital that evening, it is likely, on the balance of probability, that a different outcome would have followed.
Neglect contributed to Aman’s death.”
Aman’s medical cause of death was determined as;
1a Systemic Inflammatory Response Syndrome (SIRS)
Circumstances of the death
Shahan Abu Aman was a three year old boy born who was presented to his local ED on the evening of 7th December 2021 with symptoms of vomiting and diarrhoea. After assessment, observation and a fluid challenge he was discharged home.
The following morning Aman was found unresponsive by his mother, despite the best efforts of his family and emergency services he was declared deceased later that morning in hospital.
Coroner’s concerns
1. A series of miscommunications between; nursing staff, junior and consultant paediatric medical staff resulted in concerns regarding Aman not being properly considered prior to discharge. Staff relied on assumptions that others understood the factors affecting Aman and had a plan to resolve them, this was not the case. Had effective communication occurred it was unlikely that Aman would have been discharged.
2. The doctor who authorised discharge did not satisfy himself of the most recent set of clinical observations and associated Paediatric Early Warning Sign (PEWS) score prior to discharge.
3. The Paediatric Emergency Department was particularly busy that evening, with a combination of high patient numbers and severe acuity of symptoms. The accounts provided by Trust witnesses was that this resulted in a pressurised environment and that this was a situation that occurred with an increasing level of frequency over the last two years.
Information checked against the published report and official responses