12. In our primary investigation, we look at whether there are signs the event complained about had a negative effect which the organisation has not put right. We have done this and we have found the Trust has done enough to put things right.
Ms I’s daughter’s arrival and experience in resus
13. Ms I complains a medical team was not present on her daughter’s arrival at the Trust on 8 October 2020, and a team was also not present on her daughter’s admission to resus. Ms I says she now suffers from anxiety when attending the hospital and is taking medication as a result of the experience.
14. The clinical notes say the ambulance crew made the pre-alert call at 2.48pm. The records confirm Ms I’s daughter arrived at 2.58pm.
15. The records show the emergency department (ED) consultant was the only doctor present when Ms I’s daughter arrived at the ED. There was no paediatric team present on her arrival or following her move to resus. There was only a nurse present in resus.
16. Ms I’s daughter has a personalised seizure plan dated May 2020. It says the hospital should put out a paediatric crash call if her daughter is fitting on arrival.
17. Ms I’s daughter’s seizure started at 1.50pm at home.
18. The records show the doctor who took the pre-alert call from the ambulance service made a note of Ms I’s daughter’s name and date of birth, and recorded she was in status epilepticus (having continuous seizures). The records show the doctor took this call at 2.25pm. The records state ETA (estimated time of arrival) would be in 12 minutes.
19. The clinical notes say the ambulance crew made the pre-alert call at 2.48pm. The records confirm she arrived at 2.58pm. This is in line with the ambulance’s ETA.
20. The records show the ED consultant was the only doctor present when Miss I’s daughter arrived at the ED. There was no paediatric team present on her arrival or following her move to resus. There was only a nurse present in resus. This is not line with her personalised seizure plan.
21. The records show medical staff called the paediatric team at 3.06pm, and the team arrived in resus at 3.08pm. Nursing documentation (page 49) written in retrospect states the doctor who had taken the pre-alert call had informed the paediatric team at 2.48pm. However, documentation from the ED registrar states they asked for the paediatric consultant to be called during an initial assessment of Miss I’s daughter, at some time after her arrival in the ED. The personalised seizure plan says the call should be put out on arrival.
22. The records are unclear about when medical staff called the paediatric team. The records confirm the paediatric team was not aware of the call until 3.06pm. This was after Miss I’s daughter’s arrival, and there is evidence the personalised seizure plan was not followed.
23. The records show she arrived at the ED at 2.58pm, and medical staff gave her lorazepam at approximately 3.06pm. Her seizures had stopped by 3.13pm. She had a past history of recurrent and prolonged seizures. Our adviser said there is no evidence this event had any long-lasting effect on her later health or recovery.
24. The Trust has confirmed they did not plan properly in line with Ms I’s daughter’s personal seizure plan before her arrival at the ED. This is a sign something has gone wrong, as the Trust did not follow the personalised seizure plan. We consider what the Trust has done to put things right below.
Administration of lorazepam
25. Ms I complains the Trust did not listen to her regarding her daughter’s weight and gave her an overdose of lorazepam. As a result of witnessing this, she now suffers from anxiety when attending the hospital and is taking medication as a result.
26. The records show the Trust administered 4mg of lorazepam at 3.08pm.
27. The Trust said the delivery of the incorrect dose of lorazepam was due to a communication failure. When the nurse asked what dose of lorazepam Miss I’s daughter needed, the ED registrar (who did not know Miss I’s daughter’s weight) responded with 4mg. This was an incorrect dose based on her estimated weight for her age, not her actual weight.
28. The records show after the lorazepam had been administered, her breathing pattern slowed. Doctors made the decision to administer an anaesthetic, place a tube in her windpipe and connect her to a breathing machine (a process called intubation). Doctors intubated her at 3.40pm and then transferred her to the intensive care unit.
29. Both Ms I’s daughter’s personalised seizure plan and APLS guidance show the Trust should not have treated her with lorazepam at all. Both state a maximum of two doses of benzodiazepines (a class of medication including midazolam, diazepam and lorazepam) should be given to a child having continuous seizures.
30. The records show Ms I had administered midazolam to her daughter at home, and then the ambulance crew had administered diazepam on the way to the hospital. Both her daughter’s personalised seizure plan and the APLS guideline state intravenous phenytoin (a drug used to stop seizures which is not a benzodiazepine) is the next drug which should be given when seizures persist.
31. According to British National Formulary guidance for lorazepam, as Ms I’s daughter weighed 26kg, doctors should have administered 2.6mg, not 4mg, of the medication.
32. The Trust has recognised its failing in giving her an overdose of lorazepam. Our adviser agrees the decision to administer lorazepam and its dose were incorrect.
33. Our adviser says phenytoin must be given intravenously as an infusion over 20 minutes. It is important to note the process of setting up this infusion safely, including inserting a cannula (a small tube inserted into the vein), drawing up the drug and setting up the infusion device can take 10 to 15 minutes. Therefore, even if the Trust had taken the decision to use phenytoin immediately, there would have been a delay of 10 to 15 minutes before the infusion started, and then a period of up to 20 minutes before it stopped the seizure.
34. The records show after the Trust gave Ms I’s daughter lorazepam at 3.08pm, her seizure had stopped at 3.13pm.
35. The records show Ms I’s daughter’s blood test result taken at 3.11pm had significant abnormalities. Our adviser says her blood pH was very low (a lot of acid had accumulated in the blood), meaning her breathing had been inadequate for some time before she received the lorazepam. Giving lorazepam may have worsened this. It is clear her history of a continuous seizure for approximately one hour before arriving at the ED had already had a significant harmful effect on her. It is possible she would have needed intubation, even if she had not received the lorazepam.
36. The records show Ms I’s daughter sustained no long-term harmful impacts as a result of her assessment and treatment in the ED. Our adviser agrees with this.
37. As we have seen a sign of a failing, we consider what has been done to put this right below.
Putting things right
38. Ms I is seeking service improvements and financial compensation.
39. The Trust has confirmed it did not plan properly before Ms I’s daughter’s arrival at the ED and it has apologised for this. It has also implemented service improvements. It has reminded all clinical staff of the importance of introducing themselves and the ED team, in order to obtain relevant information from the family as soon as possible. The nursing team staff have also reflected on Ms I’s feedback and apologised.
40. The Trust has confirmed it did give Miss I’s daughter an overdose of lorazepam. The Trust has stated the ED registrar has been debriefed about their role in the drug error and referred to the educational supervisor. As part of their educational agreement, they plan to attend an APLS course, which includes the treatment of children with seizures and other emergency presentations, and emphasises the difference between treating children and adults. The Trust has reminded the ED team to obtain relevant information from the family as soon as possible, as this may improve the patient’s care. The nursing team staff involved in Ms I’s daughter’s care have all reflected on the feedback and apologise for the upset caused.
41. Ms I is also seeking financial compensation. She says she now has a diagnosis of anxiety, for which she takes medication because of the events described. Before her arrival at the ED, Ms I’s daughter’s seizure had been ongoing for one hour and eight minutes. Within eight minutes of arrival at the ED, Ms I’s daughter had received treatment, and within 15 minutes of arrival her seizure had ended. The records show she sustained no long-term harmful impact as a result of her assessment and treatment in the ED. Our adviser agrees with this.
42. We understand how difficult and worrying it is to see your child seriously unwell. We understand learning your child had been given incorrect treatment would have caused anxiety. It would likely cause Ms I to question the care her daughter receives going forward. Having said this, we cannot link this single incident to the diagnosis of anxiety for which Ms I takes medication. Her daughter had been having a seizure for over an hour before the medical treatment and she has an ongoing condition. It is likely that a diagnosis of anxiety would be due to ongoing concerns, rather than to a single incident. There was no clinical impact on Ms I’s daughter. Further, the evidence shows her seizures were stopped earlier than if phenytoin had been administered. Therefore, we do not consider financial compensation is needed.
43. We understand the events were really difficult for Ms I. We have seen the Trust has taken steps to improve its service and it has apologised to Ms I. We consider this puts right what went wrong.