UK Inquiry Tracker

Kellum Thomas

PFD Report Historic (No Identified Response) Ref: 2022-0244

Date of Report 3 August 2022

Coroner Elizabeth Didcock

Coroner Area Nottinghamshire and Nottingham

Response Deadline est. 25 November 2022

Hospital Death (Clinical Procedures and medical management) related deaths Other related deaths

Judiciary.uk Report PDF

Coroner's Concerns (AI summary)

The patient lacked a cardiac monitoring device for 18 months due to a poor system for identifying battery end-of-life and excessively long replacement waiting lists. Additionally, crucial outpatient letters were significantly delayed.

View full coroner's concerns

1. Kellum was without a REVEAL device to monitor his heart rate and rhythm for an 18 month period, despite this being an agreed necessary part of his treatment. The evidence from , Consultant Paediatric Cardiologist, was that there was no robust system for clearly identifying when a battery within a REVEAL device, came to the end of its life, nor was there a robust system for managing the list of children waiting for a replacement device. Also that the waiting list for a device change was excessively long (over 12 months for urgent cases, and longer for those less urgent). Also that capacity and resources were very stretched as the Specialist Paediatric Cardiology team dealing with these issues, was small, and covering both East and West Midlands.
2. Kellum’s outpatient letter from to both the GP and to Nottingham University Hospitals NHS Trust (where shared care was provided) was very delayed, with the outpatient appointment completed in March 21, and the letter not reaching its destinations until mid June 21, after Kellums death. This letter contained important information re a change in medication dosage and a request for NUH to arrange a further investigation. Again this issue appeared to be one of team capacity and resources. I am not reassured that necessary actions to address either of these serious issues identified are in place.

Sent To

Birmingham Women and Childrens Hospital NHS Foundation
the NHS Commissioning team

Response Status

Linked responses 0 of 2

56-Day Deadline 25 Nov 2022

About PFD responses

Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.

Source: Courts and Tribunals Judiciary

Report Sections

Investigation and Inquest

On the 11th June 2021, I commenced an investigation into the death of Kellum Paul Thomas aged thirteen years. The investigation concluded at the end of the inquest on the 8th July 2022. The conclusion of the inquest was Natural Causes.

Circumstances of the Death

Kellum collapsed at his home address around 20.00 hours on the 9th June 2021. He had a cardiac arrest from which he could not be resuscitated, and was pronounced deceased at Queens Medical Centre, at 21.37 hours on that day. He had a REVEAL device in situ, to monitor his heart rate and rhythm, which showed that he developed Ventricular Tachycardia (VT), deteriorating into Ventricular Fibrillation (VF) leading to his death. The REVEAL device had been in place from 2016 (when he very likely had a previous cardiac arrest), although the battery in this device had stopped functioning likely in September 2019. The device was not replaced until February 2021. Whilst there had been no previous documented episodes of VT or VF, only clusters of extra ventricular beats, there was a missing period of recording of heart rate and rhythm between Sept 19 and February 2021. There was no clear indication for treatment with an implantable Defibrillator based on his presentation and REVEAL device recordings, although this decision had been considered carefully. There was a working diagnosis of a rhythm disorder of the heart known as Catecholaminergic Polymorphic Ventricular Tachycardia, although this was not proven in life, though now thought likely to be the cause of his death based on the final rhythm change and the normal structure of the heart confirmed at Post Mortem examination. Kellum was seen in March 2021 by his Cardiologist, and was well. The planned increase in Atenolol was not implemented following this appointment, as the letter to the GP to initiate the change did not reach the GP until after Kellum's death. Whilst there were issues of care in this case, I cannot say they have caused or made a significant contribution to his death on a balance of probability, as the fatal rhythm change had not been demonstrated previously, and Kellum had had no ongoing symptoms to suggest he was at risk of a fatal arrhythmia.