UK Inquiry Tracker

Edward Joyce

PFD Report Partially Responded Ref: 2018-0142

Date of Report 9 May 2018

Coroner Philip Barlow

Coroner Area London Inner (South)

Response Deadline ✓ from report 6 July 2018

Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths

Judiciary.uk Report PDF

Coroner's Concerns (AI summary)

A child's critical high temperature following a burn was missed by the GP and not recorded or acted upon by hospital staff, highlighting inadequate awareness of burn complications and follow-up advice.

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May The they him the

: _ The evidence at the inquest was that a temperature reading above 38'C following a burn to a young child is highly concerning; and could be an early sign of septicaemia and toxic shock syndrome (1) The temperature reading of 38.9'C at the GP did not trigger an urgent referral to hospital.

(2) Eddie's mother was clear that she reported this temperature reading to the nurse at Chelsea & Westminster when she telephoned soon after the GP appointment: This reading is not recorded in the telephone note and the parents were not told to bring Eddie back to hospital: (3) The evidence was that scalding injuries amongst children are very common but that toxic shock syndrome is very rare. In their evidence the hospital witnesses helpfully considered whether the information leaflet could be reviewed so as to assist other health professionals who may be less aware of the potential significance of high temperature following a burn and the availability of 24 hour telephone advice the burns unit,

Responses

Chelsea and Westminster Hospital NHS Trust NHS / Health Body

25 Oct 2019

Noted
The Trust states the evidence indicates a temperature spike was not mentioned during the phone call, and the national information leaflet contains accepted advice and correct symptoms for burns injuries. The Paediatric Burns Network has been alerted, and the burns unit can be contacted by telephone 24 hours every day. (AI summary)

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Dear Mr Barlow, Master Edward (Eddie) Joyce(RIP) Inquest 4 May 2018 The Trust is in receipt of the Regulation 28: Report to Prevent Futures Deaths notice (PFD made by you on 9 May 2018 and issued to Trust and to General Practitioner Further to our earlier correspondence and your clarification of 26 July can confirm the following as the Trust's response which focuses issues identified as directly of concern to the Trust It is the Trust's understanding that the evidence from Nurse explained the action that would have been taken if a spike in temperature was mentioned during the relevant telephone call but there was no suggestion that a spike in temperature was mentioned and not recorded acted on With regard to the national information leaflet; it does set out the warning signs to look out for in a child who has sustained a burns injury and is developing sepsis or Toxic Shock Syndrome (TSS); can confirm that the existing leaflet contains nationally accepted advice in attending to burns injuries in children. It also contains the correct symptoms (red flags) and the correct advice as to what parents ought to do if concerned, including where to seek further treatment and advice_ We have also alerted the Paediatric Burns Network to your advice so that any improvements can be made more widely. We would also to reassure you that our burns unit can already be contacted by telephone 24 hours every day: would also Iike to clarify on behalf of the Trust the PFD notice states at concern (3) that the 'evidence was that scalding injuries amongst children are common but that Toxic Shock Syndrome (TSS) is rare' however we respectfully submit that was clear in her evidence that TSS is very common with approximately one child per on ward monitored for suspected TSS. hope that this response addresses concerns raised but please do not hesitate to contact me directly if there is any further information that you require at this stage

Sent To

Chelsea & Westminster Hospital
Medical Protection Society

Response Status

Linked responses 1 of 2

56-Day Deadline 6 Jul 2018

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 29 November 2017 commenced an investigation into the death of Edward Joyce age 17 months_ The investigation concluded at the end of the inquest on 4 2018 . conclusion of the inquest was: Medical cause of death: Ia) Septic Shock 1b) Infected burns_ How, when and where the deceased came by his death: Edward Joyce Eddie" = age 17 months, suffered an accidental burn on 19 November 2017 and was treated at Chelsea & Westminster Hospital. On 21 November he was seen by his GP and found to have a temperature of 38.9C. This reading did not trigger a referral back to hospital. On 22 November Eddie's condition significantly deteriorated. He was taken to University Hospital Lewisham where he died despite prolonged attempts at resuscitation Narrative conclusion: Edward Joyce died after developing septic shock from an accidental scalding injury.

Circumstances of the Death

Eddie was admitted overnight at Chelsea & Westminster hospital and went home on 20 November: His parents were given an information leaflet and an appointment to be seen again on 23 November: The information leaflet states that a child may need to be seen sooner if show a fever above 38'C or vomiting: On 21 November Eddie's mother took to the GP where he was diagnosed with an ear; throat and eye infection. During the appointment his temperature was noted to be 38.9%C_ After this appointment Eddie's mother telephoned the paediatric burns unit at Chelsea & Westminster,. Her evidence was that she reported the temperature reading at GP of 38.9PC , and that the temperature had now come down to 37.6*C_ The record of this telephone call recorded that the temperature was "37.6 % no higher" and that there had been one small vomit: Neither the GP nor the hospital nurse told Eddie's parents to bring him back to hospital, On 22 November Eddie became severely unwell. His parents telephoned Chelsea & Westminster again and were told to take him to their local A&E department He collapsed as they arrived and died despite attempts at resuscitation.

Action Should Be Taken

In my opinion action should be taken to prevent future deaths and believe you andlor your organisation have the power to take such action: