Alfie Rose · Prevention of Future Deaths report

On 22/06/2016 I commenced an investigation into the death of Alfie Rose aged 17. The investigation concluded at the end of an inquest on 26th October 2016. The conclusion of the inquest was:

Alfie died from complications of obstructive hydrocephalus. Earlier detailed MRI scan, admission and treatment at Queen Elizabeth Hospital neurosurgical unit on 16/05/16, 27/05/16 and the morning of 06/06/16 would, on balance, have avoided his death.

The deceased had suffered from hydrocephalus as a child. He had not required any treatment during childhood. On 02/05/16 he presented to Russell’s Hall Hospital complaining of a headache for two weeks. Scans revealed generalized ventricular dilatation compatible with likely arrested hydrocephalus. An ophthalmology examination found evidence of papilloedema resulting in an urgent referral to outpatients at Queen Elizabeth Hospital in Birmingham. He was seen in the neurosurgery hot clinic at Queen Elizabeth Hospital on 16/05/16 when doctors advised he should be admitted for further assessment and treatment. He refused admission so arrangement was made for further follow up in out patients clinics. On 27/05/16 he presented to his GP with headache of increasing severity. He was referred to Russell’s Hall Hospital where further scans were undertaken which were unchanged from before. He was discharged home. He presented to Russell’s Hall hospital emergency department at 11am on 06/06/16 complaining of further headaches. An MRI scan was undertaken which was unchanged from before and his symptoms resolved so he was discharged home. He returned to the emergency department at 22.22 complaining of a headache and vomiting. He was taken to the high dependency side of the department. At approximately 00.30 he had a sudden deterioration and respiratory arrest requiring full resuscitation. A further CT scan was undertaken confirming severe hydrocephalus. He was transferred as an emergency to Queen Elizabeth Hospital in Birmingham leaving at 04.38 and arriving at 05.34. An external ventricular drain was inserted immediately on arrival. Further assessment confirmed extensive brain infarction indicating a severe brain injury. He died at 11.33 on 09/06/16 following organ donation.

Based on information from the Deceased’s treating clinicians, the medical cause of death was determined to be:

BRAIN STEM DEATH
OBSTRUCTIVE HYDROCEPHALUS

1. There was poor communication between both hospitals in relation to Alfie’s condition and care. Details of his neurosurgical review on 16/05/16 were not made available to Russell’s Hall Hospital. His clinical condition was not relayed to QE hospital on 27/05/16 or morning of 06/06/16. These were vital missed opportunities to transfer him back to QE for treatment. Both Trusts need to look at their communication systems and identify areas for improvement and to clarify if the NORSE system is effective. I heard evidence to suggest that all the NORSE system entries cannot always be seen.

2. Education. It is important the clinicians in outlying hospitals understand how neurological referrals should be made and when. Better guidance and education is needed for outlying hospitals.