JACKSON TERRY SELLERS MITCHELL · Prevention of Future Deaths report

On 12 May 2014 I commenced an investigation into the death of JACKSON TERRY SELLERS MITCHELL, AGE 6 DAYS. The investigation concluded at the end of the inquest on 15 OCTOBER 2014. The medical cause of death was 1(a) INTRAPERITONEAL EXTRAVASATION OF PARENTERAL NUTRITION SOLUTION AS A CONSEQUENCE OF 1(b) UMBILICAL VEIN CATHETERISATION and PART II PREMATURITY and the conclusion of the inquest was DEATH DUE TO A RARE BUT RECOGNISED RISK OF NECESSARY MEDICAL TREATMENT.

Jackson was born prematurely at 31 weeks gestation at Queen Elizabeth Hospital, King's Lynn with a low birth weight of 1.78 kilograms. An umbilical venous catheter (UVC) was inserted to give parenteral nutrition feeding and fluid management.

A heart murmur was detected on the morning of 8 May 2014. On evening of 8 May 2014 Jackson developed abdominal distension. In the light of the clinical picture a diagnosis was made of necrotising enterocolitis. Evidence was given that in the light of the presenting symptoms this was a reasonable diagnosis to make. A nasogastric tube was inserted to drain the fluids, Jackson was placed on nil by mouth and triple antibiotics were started.

Jackson required cardio-pulmonary resuscitation.

Arrangements were made for transfer to Norfolk & Norwich University Hospital (NNUH) which occurred at 8:40 am on 9 May 2014. A surgical drain was inserted and milky fluid was aspirated. The neonatal team at NNUH felt the presentation was due to extravasation of total parenteral nutrition solution and not necrotising enterocolitis. A large amount of fluid was drained before and after Jackson's transfer to the NNUH. The UVC was removed. Jackson continued to deteriorate and he died at 05:05 on 10 May 2014.

Post Mortem Report gives the cause of death as 1a) Intraperitoneal extravasation of parenteral nutrition solution b) Umbilical vein catheterisation 2. Prematurity. The Post Mortem identified damage to Jackson's liver compatible with injury from the parenteral nutrition solution, which is currently deemed to be a “very rare” complication. There was no evidence of direct vessel perforation from the umbilical venous catheter tip.

The damage found to Jackson's liver at post mortem does not appear to be from the tip of the catheter but from the concentrated feeding fluid that was passing through it.

Evidence was given that the ideal placement for a UVC tip is at the level of the diaphragm at approximately T9-T10 vertebral level. The UVC in this case was found to be in a lower lying position, but one which is presently acceptable to 80% of Doctors.

There is a presently unpublished study from Southampton which found 16 cases of extravasation of fluid from UVC over a 2 year period. Extravasation was shown following routine screening of ultra sound scans, although in the study there were no fatalities. Most of the complications in the study occurred with low lying catheters.

Further investigation is being carried out into the positioning of catheters and problems of extravasation of the fluid from UVC. It is understood NHS England are looking into whether any lessons can be learned from this case.

No criticism was expressed at the inquest of any of the medical team involved in the care of Jackson.