Coco Bradford
PFD Report
All Responded
Ref: 2022-0012
All 1 response received
· Deadline: 15 Mar 2022
Coroner's Concerns (AI summary)
Outdated IV fluid guidelines for children in shock posed a risk of fluid overload, and there was no clear guidance on balancing antibiotic use for sepsis against the risk of HUS in bacterial gastroenteritis.
View full coroner's concerns
Information Classification: CONTROLLED
1) In April 2009, NICE published CG 84 on Diarrhoea and Vomiting caused by gastroenteritis in Under 5s and management. Paragraph 1.3.3 deals with IV fluid management for patients presenting with shock. The guidance suggests rehydration with rapid IV infusion at 20mls/kg. The guidance is now a little dated and it is at odds with the Resuscitation Council UK Guidelines issued in 2021 which provide that for children and infants presenting with shock, fluid should be given in boluses of 10mls/kg – there is an emphasis on smaller bolus volumes with careful re-assessment after each bolus to enable early identification of signs and symptoms of fluid overload. This was particularly relevant in Coco’s treatment where there was concern she may develop HUS with associated compromise of kidney function. As there appears now to be a move towards smaller boluses of fluid with more frequent review, it may be that you will also feel it appropriate to reconsider when to escalate care to colleagues in intensive care i.e. whether it should still be after two boluses or after a particular total amount of fluid.
2) A second issue that came out of Coco’s inquest was the clinical conundrum of how to treat a child with bacterial (e coli 0157) gastroenteritis who is suspected of having a concomitant sepsis. The dilemma is that the administration of antibiotics may precipitate or worsen HUS and, if the child is subsequently found not to have sepsis, may inadvertently cause harm. It may be that you will feel that guidance on how to weigh the balance of risk and who to involve in the decision-making process would be of assistance to clinicians generally.
1) In April 2009, NICE published CG 84 on Diarrhoea and Vomiting caused by gastroenteritis in Under 5s and management. Paragraph 1.3.3 deals with IV fluid management for patients presenting with shock. The guidance suggests rehydration with rapid IV infusion at 20mls/kg. The guidance is now a little dated and it is at odds with the Resuscitation Council UK Guidelines issued in 2021 which provide that for children and infants presenting with shock, fluid should be given in boluses of 10mls/kg – there is an emphasis on smaller bolus volumes with careful re-assessment after each bolus to enable early identification of signs and symptoms of fluid overload. This was particularly relevant in Coco’s treatment where there was concern she may develop HUS with associated compromise of kidney function. As there appears now to be a move towards smaller boluses of fluid with more frequent review, it may be that you will also feel it appropriate to reconsider when to escalate care to colleagues in intensive care i.e. whether it should still be after two boluses or after a particular total amount of fluid.
2) A second issue that came out of Coco’s inquest was the clinical conundrum of how to treat a child with bacterial (e coli 0157) gastroenteritis who is suspected of having a concomitant sepsis. The dilemma is that the administration of antibiotics may precipitate or worsen HUS and, if the child is subsequently found not to have sepsis, may inadvertently cause harm. It may be that you will feel that guidance on how to weigh the balance of risk and who to involve in the decision-making process would be of assistance to clinicians generally.
Responses
Action Planned
NICE acknowledges the guideline on gastroenteritis in under 5s [CG84] does not align with the UK Resuscitation Council’s 2021 guideline on paediatric advanced life support, and has forwarded the report to their guideline surveillance team who will review the UK Resuscitation Council’s 2021 guideline and consider if CG84 and other related NICE guidance need to be updated. (AI summary)
NICE acknowledges the guideline on gastroenteritis in under 5s [CG84] does not align with the UK Resuscitation Council’s 2021 guideline on paediatric advanced life support, and has forwarded the report to their guideline surveillance team who will review the UK Resuscitation Council’s 2021 guideline and consider if CG84 and other related NICE guidance need to be updated. (AI summary)
View full response
Dear Mr Cox,
I write in response to your regulation 28 report of 18 January 2022 regarding the very sad death of Coco Bradford. I would like to offer my sincere condolences to Coco’s family.
Your report, which has been reviewed by our internal patient safety team and chief medical officer, states that the NICE guideline on the diagnosis and management of diarrhoea and vomiting caused by gastroenteritis in under 5s [CG84] is not in line with the UK Resuscitation Council’s 2021 guideline on paediatric advanced life support. Having reviewed the guidance, we agree that the volume of fluid bolus does not align and as a result of this being highlighted, we have also looked at our other guidance of relevance.
It is important to note that CG84 covers diagnosing, managing and referring infants and young children younger than 5 years who present with acute diarrhoea with or without vomiting. We have not published guidance on this topic for people aged 5 years and older. However, we do have separate guidance that does cover children over 5 years of age on the recognition, diagnosis and early management of sepsis [NG51 from 2017] and guidance [NG29 from 2020] covering intravenous fluid replacement for children in hospital. All of this guidance has been reviewed considering your report, for their alignment to the 2021 UK Resuscitation council guidance.
In light of our initial review, your report has now been forwarded to our guideline surveillance team who will review the UK Resuscitation Council’s 2021 guideline and consider if CG84 and other related NICE guidance need to be updated.
Finally, you also note the difficulty of treating a child with bacterial gastroenteritis who is suspected to have concomitant sepsis and ask if guidance on ‘how to weigh the balance of risk and who to involve in the decision-making process’ would be useful. Reflecting on the specific issue raised in your report, that ‘the administration of antibiotics may precipitate or worsen [haemolytic uraemic syndrome] and, if the child is subsequently found not to have sepsis, may inadvertently cause harm’, we consider this to be a matter of clinical judgement and not something that could be addressed by a guideline. Haemolytic uraemic syndrome is
Page | 2
Information Classification: CONTROLLED however considered in the NICE Clinical Knowledge summary on gastroenteritis last revised in August 2020.
Please do let me know if you require any further information and again, I offer my sincerest condolences to Coco's family.
I write in response to your regulation 28 report of 18 January 2022 regarding the very sad death of Coco Bradford. I would like to offer my sincere condolences to Coco’s family.
Your report, which has been reviewed by our internal patient safety team and chief medical officer, states that the NICE guideline on the diagnosis and management of diarrhoea and vomiting caused by gastroenteritis in under 5s [CG84] is not in line with the UK Resuscitation Council’s 2021 guideline on paediatric advanced life support. Having reviewed the guidance, we agree that the volume of fluid bolus does not align and as a result of this being highlighted, we have also looked at our other guidance of relevance.
It is important to note that CG84 covers diagnosing, managing and referring infants and young children younger than 5 years who present with acute diarrhoea with or without vomiting. We have not published guidance on this topic for people aged 5 years and older. However, we do have separate guidance that does cover children over 5 years of age on the recognition, diagnosis and early management of sepsis [NG51 from 2017] and guidance [NG29 from 2020] covering intravenous fluid replacement for children in hospital. All of this guidance has been reviewed considering your report, for their alignment to the 2021 UK Resuscitation council guidance.
In light of our initial review, your report has now been forwarded to our guideline surveillance team who will review the UK Resuscitation Council’s 2021 guideline and consider if CG84 and other related NICE guidance need to be updated.
Finally, you also note the difficulty of treating a child with bacterial gastroenteritis who is suspected to have concomitant sepsis and ask if guidance on ‘how to weigh the balance of risk and who to involve in the decision-making process’ would be useful. Reflecting on the specific issue raised in your report, that ‘the administration of antibiotics may precipitate or worsen [haemolytic uraemic syndrome] and, if the child is subsequently found not to have sepsis, may inadvertently cause harm’, we consider this to be a matter of clinical judgement and not something that could be addressed by a guideline. Haemolytic uraemic syndrome is
Page | 2
Information Classification: CONTROLLED however considered in the NICE Clinical Knowledge summary on gastroenteritis last revised in August 2020.
Please do let me know if you require any further information and again, I offer my sincerest condolences to Coco's family.
Sent To
- National Institute for Health & Care Excellence
Response Status
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56-Day Deadline
15 Mar 2022
All responses received
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Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 14/1/22, I concluded an inquest into the death of Coco Bradford, a 6-year-old girl who died in Bristol Royal Hospital for Children on 31/7/17. . The medical cause of death was recorded as: 1a) Multiple organ failure 1b) E-coli 0157 associated Haemolytic Uraemic Syndrome 1c) II)
I recorded a Narrative Conclusion that Coco died from natural causes, in particular, a severe form of haemolytic uraemic syndrome, a known but rare complication of an e-coli 0157 bacterial infection.
I recorded a Narrative Conclusion that Coco died from natural causes, in particular, a severe form of haemolytic uraemic syndrome, a known but rare complication of an e-coli 0157 bacterial infection.
Circumstances of the Death
Coco was a 6-year-old girl with an established diagnosis of autism. On 25/7/17, she presented to the Emergency Department at Royal Cornwall Hospital with diarrhoea and vomiting. It was suspected she had gastroenteritis. She was treated and discharged with standard advice to return if her condition deteriorated. On 26/7/17, she re-presented more unwell. She was admitted with a working diagnosis of bacterial gastroenteritis and, as she had features of shock, she was subsequently given several boluses of IV fluids. Her condition improved temporarily after each bolus, but the improvements were not sustained and over the course of 27/7/17 she progressively deteriorated. Haemolytic uraemic syndrome (HUS) was suspected and confirmed on blood results later that night. There was concern she also had a concomitant sepsis, but this was not demonstrated on blood cultures only reported after her transfer to Bristol. She was transferred to the Intensive Care Unit on the morning of 28/7/17. After resuscitation and stabilisation, she was transferred to the paediatric intensive care unit in Bristol. Despite further treatment, she continued to deteriorate and died at Bristol Royal Hospital for Children on 31/7/2017.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.