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Inquest Hears How Boy Died After Doctor Mistook Him for DNR Patient

By Senior Associate, Clinical Negligence

A trial has heard how a six-year old boy died after a doctor “inexplicably” confused him with another patient.

DNR
Nottingham Crown Court heard how Dr Hadiza Bawa-Garba - who denies manslaughter through gross negligence - called off attempts to save the boy’s life because she mistakenly believed he was under a ’Do Not Resuscitate Order.’

Jurors heard how a junior doctor spotted the mistake and a team of medics attempted to revive the boy. But sadly, it was too late and he was pronounced dead.

The Leicester boy stopped breathing hours after he was admitted to Leicester Royal Infirmary with pneumonia in February 2011. He eventually died from a cardiac arrest after a bacterial infection triggered sepsis.

Dr Bawa-Garba and two nurses were later charged with manslaughter through gross negligence. All three worked on the hospital’s Children’s Assessment Unit (CAU). According to prosecutor Andrew Thomas QC, the trio failed in their duty of care to the child and were all responsible for a series of blunders involving his treatment.

“The prosecution say their conduct was grossly negligent: truly, exceptionally bad; amounting to a criminal offence,” said Mr Thomas.

High-Risk Patient

The court heard how the boy’s parents took their son to his GP when he began suffering with diarrhoea, sickness and breathlessness. He was immediately referred to the Leicester Royal Infirmary. But when he was taken to the CAU, he was assessed by two nurses, one of whom had no children’s nursing qualifications. Crucially, both nurses failed to flag him as a high-risk patient.

Jurors heard that by this point, the child was turning blue around the lips and was already suffering from the deadly infection sepsis. Dr Bawa-Garba then wrongly diagnosed him with gastroenteritis.

“His body was shutting down because of the spread of the infection and had gone into shock” said Mr Thomas. “The defendants failed to recognise that condition and act on it…the signs had been there from the outset and should have been perfectly obvious to a competent doctor.”

Mr Thomas said the boy’s vital signs were only checked twice during his time in the CAU and even then the record was “woefully incomplete.”

When the boy went into cardiac arrest that evening, a team of doctors and nurses began attempts to revive him but were told “almost immediately” to stop by Dr Bawa-Garba who said he had been marked down as ‘Do Not Resuscitate’ earlier that day.

A junior doctor then read the boy’s notes with another colleague and when neither could find the DNR entry, they immediately raised it with senior doctors. When the notes were handed to Dr Bawa-Garba she realised her error and announced that the boy was to be resuscitated after all.

Dr Bawa-Garba later explained that she had confused the boy with another child she had been treating on the CAU earlier. She admitted that she had not been “on top of things” after working a 12-hour stint without a break.

This is a truly tragic example of health workers failing to notice the seriousness of sepsis symptoms. If they had recognised the severity of this boy’s condition and acted quickly to counteract the effects of sepsis, his risk of death may well have been minimised.

Every year, around 37,000 people die in the UK after being admitted to hospital with sepsis. Symptoms include: fevers, chills, diarrhoea, vomiting and dizziness. Sadly, the failure to recognise and manage sepsis in the NHS is a continuing problem, particularly when patients are admitted to hospital over the weekend.

Nisha Sharma is a Senior Clinical Negligence Solicitor at Slater and Gordon in London.

If you or a member of your family suffered from negligent treatment in hospital, call our Medical Negligence Solicitors for a free consultation on freephone 0800 916 9049 or contact us online.

Clinical Negligence, clincial negligence blog, clin neg blog, Sepsis

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