Adam Bojelian
PFD Report
0 of 1 responses identified
Ref: 2020-0116
Coroner's Concerns (AI summary)
The Trust failed to maintain nurse training records, preventing assurance of competence, and neglected to create a formal care plan for a critically ill child, leading to disputed treatment.
View full coroner's concerns
_ (1) Training Records for Nurses_ The evidence revealed that in 2015, the Trust did not hold records of the training received by individual nurses_ Instead, it was left to each individual nurse to maintain their own training records_
The concern arising from this is that; without accurate records, a Trust cannot be sure a particular nurse has the required skills and competence to out a particular task Instances of this revealed at the Inquest was whether nurses on ward 40 at LGI had received training in relation t0 Bair Huggers or BiPAP ventilation equipment used in the care of critically ill children.
(2) Formal Written Care Plans The evidence taken at the inquest revealed that despite the complex medical needs of this child, no formal written care plan was created for the period he was in hospital, from September 2013 to January 2015 (15 months) It was assumed all the clinicians involved would glean sufficient information from a review of his notes_ The absence of a plan meant that aspects of his treatment were not exposed as being controversial (and disputed by his parents): An example of this related to hydrocortisone therapy_ In complex cases, a comprehensive care plan would provide both parents and clinicians with a basis upon which t0 obtain a second opinion from an independent source in the event of a dispute, as occurred repeatedly in this case_
The concern arising from this is that; without accurate records, a Trust cannot be sure a particular nurse has the required skills and competence to out a particular task Instances of this revealed at the Inquest was whether nurses on ward 40 at LGI had received training in relation t0 Bair Huggers or BiPAP ventilation equipment used in the care of critically ill children.
(2) Formal Written Care Plans The evidence taken at the inquest revealed that despite the complex medical needs of this child, no formal written care plan was created for the period he was in hospital, from September 2013 to January 2015 (15 months) It was assumed all the clinicians involved would glean sufficient information from a review of his notes_ The absence of a plan meant that aspects of his treatment were not exposed as being controversial (and disputed by his parents): An example of this related to hydrocortisone therapy_ In complex cases, a comprehensive care plan would provide both parents and clinicians with a basis upon which t0 obtain a second opinion from an independent source in the event of a dispute, as occurred repeatedly in this case_
Sent To
- Leeds Teaching Hospitals NHS Trust
Responses Identified
Responses identified
0 of 1
56-Day Deadline
17 Aug 2020
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 27th March 2015 an investigation was commenced into the death of Adam Alexander Bojelian, aged 15,The investigation concluded at the end of the Inquest on 3r February 2020.The conclusion of the Inquest was natural causes_ The medical cause of death was: 1a Multiorgan failure Multiagent infection: Enterococcus faecium , Serratia marcescens and Candida sp Quadriplegic cerebral palsy
Circumstances of the Death
Adam Alexander Bojelian suffered a severe birth injury and was profoundly disabled due to quadriplegic cerebral palsy, epilepsy; chronic lung disease and other conditions_ He was admitted into hospital in September 2013 and remained in hospital for some 17 months until taken t0 a hospice on the eve of his death on 24/03/15. His parents were concerned at the quality of his care in the hospital and pressed for him to be admitted to a paediatric intensive care unit (PICU): The treating doctors did not consider this was_ required until 25/02/15,when he was transferred to PICU_
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe your organisation has the power to take such action
Similar PFD Reports
Reports sharing organisations, categories, or themes
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Care planning system
Vale of Leven Inquiry
Inaccurate and inaccessible patient records
Care plan failures
Relative discussions recorded
Vale of Leven Inquiry
Inaccurate and inaccessible patient records
Care plan failures
TVN instructions recorded
Vale of Leven Inquiry
Inaccurate and inaccessible patient records
Care plan failures
Wound documentation
Vale of Leven Inquiry
Inaccurate and inaccessible patient records
Care plan failures
Positional change records
Vale of Leven Inquiry
Inaccurate and inaccessible patient records
Care plan failures
Fluid balance monitoring
Vale of Leven Inquiry
Inaccurate and inaccessible patient records
Care plan failures
DNAR decision awareness
Vale of Leven Inquiry
Inaccurate and inaccessible patient records
Care plan failures
Ensure foster carers receive continuing support and access to specialist services
Waterhouse Inquiry
Staff training and development
Care plan failures
Training for IPC professionals engineers and clinicians
Scottish Hospitals Inquiry
Staff training and development
IPC role specifications and staffing levels
Scottish Hospitals Inquiry
Staff training and development
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.