Monitoring and observations
8.Mr Y’s concern is that T was not appropriately monitored and observed during her admission and this might have been a factor in her death.
9. There is no single national system in England for monitoring or observing children and young people in hospital settings. As a result, most NHS trusts have developed their own programmes. These include paediatric early warning scores, initiatives and technology for improving the accuracy of taking and recording observations and the timely escalation of care.
10.PEWS stands for Paediatric Early Paediatric Early Warning System, which is designed to effectively recognize and respond to deterioration in children or young people in a healthcare environment. It typically involves an observation chart and track and trigger system, which captures vital signs (such as heart rate) or observations (breathing) to give a total score describing how unwell a patient is and this then links the score to specific escalation responses. The Trust operated a system like this.
11.In this case, the records show that T did have regular observations. We considered whether they were regular enough. Our adviser commented that where the PEWS score was above four, observations should be repeated within 30 minutes. This did happen at first in T’s case, but briefly at around midnight it slipped to every 40 minutes, which we think was a shortcoming in the care. By 12.40am T’s PEWS score was recorded as two, which justified a longer gap between readings.
12.We looked closely at T’s records with our adviser and saw nothing to show that her condition deteriorated during her admission. We concluded that even if there were more observations, these would not have triggered any escalation, or change of treatment, like having ventilatory support. T’s death was a sudden, unexpected and unusual event. In our view, more observations would not have changed T’s treatment or prevented what happened.
13.In summary, we think T’s care was generally in line with what guidance there is in this area and it was appropriate in the circumstances. Although the timing of her regular observations slipped by a few minutes for a short period, we agree with our adviser that this was not a significant failing. It had no effect on the outcome. We have decided there were no significant failings in the way T was monitored and observed.
Oxygen
14.Mr Y complains that T should have been kept on supplementary oxygen for longer, including when the attempt was made to cannulate her.
15.T seemed to need a significant amount of extra oxygen to maintain reasonable levels, so removing the oxygen would almost certainly cause her levels to drop. If her level dropped to very low, we agree with Mr Y that it could contribute to a cardiac arrest.
16. Our adviser said that all recorded oxygen saturations after T’s initial observations were within acceptable levels. We found no evidence in her records to suggest that T’s levels ever dropped to very low, that is low enough to contribute to a cardiac arrest. The evidence in the records strongly suggested to us that T had appropriate levels of oxygen during her admission.
17.There is a record of T struggling to keep the oxygen mask on, which is not unusual in children. But, the records also showed that she seemed settled and playful which, our adviser explained, was another factor which made it less likely that her oxygen levels were seriously low.
18.Mr Y told us that the ‘oxygen was removed for I would say a couple of minutes as the wall oxygen would not reach to the chair where cannulation as attempted’. Although we saw nothing in the records to show that is what happened, we do not dispute Mr Y’s account. As we have explained, removing the oxygen for any length of time would almost certainly have caused T’s levels to drop. But we do not believe the circumstances described by Mr Y would have led to T’s oxygen levels dropping so low during the attempt to cannulate her, that it could be said to have caused the cardiac arrest.
19.Having looked closely at T’s records with our adviser, we found no evidence to support Mr Y’s view that T should have been kept on supplementary oxygen for longer, or anything to suggest that T’s oxygen saturation levels fell to unacceptable levels. We believe T was given appropriate levels of oxygen and we concluded there were no significant failings with this part of the complaint.
Cannulation and cardiac arrest
20.Mr Y thought the attempt to cannulate T might have contributed to her death and the Trust's view that these two events happening close together was likely to have been coincidental might not be reasonable.
21.Where clear guidance exists, we use that to decide whether what happened was in line with should have happened. But, there is a lack of national guidance on the management of very young children with wheeze so we have to look to the NICE guideline on bronchiolitis in children. The lack of clear guidance means that to compare what happened with what should have happened, we need to consider whether the care provided was in line with recognised, standard practice or what we would normally expect to see in similar cases.
22. In this case, we noted that T deteriorated dramatically immediately after cannulation. Our adviser explained that while it is true that children may compensate clinically while deteriorating medically (look well but be struggling below the surface) this would normally be clear from abnormal blood tests, specifically the blood gas and glucose results. These bloods, taken at the time of cannulation, were normal or nearly normal, suggesting that T was not needing to compensate and not at immediate risk of deterioration.
23.We considered whether it was appropriate to cannulate T. We think it was. Our adviser explained that cannulating children in this setting is extremely common and routine. It happened in far more cases than not in circumstances like T’s. Cannulation is standard practice and considered virtually risk-free. We found no evidence or documented cases of cannulation leading to cardiac arrest in children. Cannulation in a large number of cases worldwide will have been the way to give life-saving treatment.
24.The immediate reason for inserting the cannula in T’s case was to give magnesium. Our adviser confirmed the Trust likely also planned to give antibiotics or other treatments if the magnesium did not work. We think the Trust acted reasonably when it decided to cannulate.
25.Looking at the decision to give magnesium, there is no clear guidance supporting this as being the ‘right’ thing to do in a clinical situation like this. Our adviser explained it is the widespread, standard practice in cases like T’s. It is the same treatment T would have been given in any other hospital. We agreed with our adviser’s view and concluded that the Trust acted reasonably when deciding to try magnesium.
26.In summary, we think the attempt to cannulate was reasonable and in line with standard practice. It could not have been predicted that cannulation would cause any serious negative reaction in T’s case. And we do not think the cardiac arrest could have been prevented.
27.We understand Mr Y’s concern here. Because T’s deterioration followed the cannulation, we can see why he thinks it might have been at least a contributing factor in the cardiac arrest. Although we cannot be definite and this is only our opinion, on balance we tend to agree with Mr Y that the attempt to cannulate was likely to have been a contributing factor and not just a ‘coincidence’.
28.We looked carefully at the Trust’s explanation and response to Mr Y’s original complaint, including the note of their meeting on 22 March 2023 and the Trust’s written reply provided on 20 October 2022. We believe the explanation and response was reasonable.
29.We mostly agree with the content of the Trust’s responses and with its interpretation of events. We do not think T’s death was caused by any failings in her care or that it could have been predicted or avoided. We do not believe there were any significant failings in T’s care.
30.For the reasons we have explained and based on the evidence we have seen, we have decided not to uphold this complaint.