Last week the senior coroner for the Eastern area of Greater London, Ms Nadia Persaud, issued a Regulation 28 Report for the Prevention of Future Deaths to Barts Health NHS Trust following an inquest heard by her into the death of Caliel Arlington Smith-Kwami in August 2016.
The coroner found that at about 28 hours of age, Caliel suffered a severe hypoglycaemic episode and it was likely that this caused him significant brain damage. Under the care of the trust, various tests were carried out to identify the cause of the hypoglycaemia. The tests ultimately revealed likely hyperinsulinism, but a decision was made to discharge Caliel before those test results were available and no follow up was arranged even when some of the results become available. Caliel was seen by his health visitor a few days later and although she was aware of his medical history, hospital admission and the fact that test results were awaited, she did not investigate further. No follow up appointment was arranged and approximately two weeks later Caliel deteriorated and passed away. His cause of death was persistent neonatal hyperinsulinaemic hypoglycaemia.
As part of her investigation, the coroner found that there were a number of issues in Caliel’s care, including the delayed test results due to a problem with a lab analyser and having no system in place to flag that delay and consider its implications; the decision to discharge Caliel without the test results being available; no follow up on those test results; and no action being taken when the results were later available. It was her finding, based on the evidence she heard, that had the trust ensured that the test results were obtained and properly considered, Caliel would have been admitted for specialist monitoring, investigation and treatment and on the balance of probabilities would have survived. She was concerned that the failures in Caliel’s case, which led to him losing the chance of successful treatment, were such that they could happen again and so issued her report to ensure that the trust takes the necessary steps to change its systems.
Philippa Luscombe, partner in the clinical negligence team at Penningtons Manches, comments: “We deal with a number of cases involving unexpected deaths which lead to an inquest being held. Whilst the primary purpose of an inquest is to look at an unexpected death and determine who died, when, where and why or how, part of the coroner’s role is to consider whether there is a risk of future deaths arising in the same way and if that risk could be managed or removed.
“It is clear that the coroner in Caliel’s case felt that the care he received was not adequate and that had he received suitable care, he would have survived. Her report will therefore require the trust to look at its systems of availability and reporting of test results for babies with similar presentation and ensure that there is a structured and joined up approach. That obviously will not take away the devastating loss that Caliel’s family have suffered, but is an example of where a coroner can ensure that lessons are learned and steps are taken to try to ensure other families do not have to suffer the same events.”