Maria Voisin is Her Majesty’s Coroner for Avon. On 23rd January 2014 at the conclusion of the inquest into the death of four year old Sean Turner she found that there were “missed opportunities” in his treatment at the Bristol Royal Hospital for Children (BRHC), but that there was “no gross failure to provide basic care”. Sean’s inquest followed a 2013 inquest into the death of Luke Jenkins at the hospital
University Hospitals Bristol NHS Foundation Trust tells parents that “as a regional centre, Bristol Royal Hospital for Children sees some of the sickest children with the most complex needs, from across the South West of England and South Wales”. That is why Sean’s parents trusted the BRHC to provide him with good quality specialist care, not just basic care.
The findings of Professor Sir Ian Kennedy’s Inquiry into Bristol’s Paediatric Cardiac Services published in 2001 still apply to Bristol:
“Standards of care: parents taking their children to be treated in Bristol assumed that the level of care provided would be good. Their children were cared for in a `supra regional centre’ designated as such by the Department of Health. They trusted the system. Few had any idea that there were no agreed standards of care for PCS (Paediatric Cardiac Surgery) or for any other specialty. For the future, there must be two developments. There must be agreed and published standards of clinical care for healthcare professionals to follow, so that patients and the public know what to expect. There must also be standards for hospitals as a whole. Hospitals which do not meet these standards should not be able to offer services within the NHS.”
Nearly thirteen years after the Kennedy Report, Bristol’s standards of care are still hidden from parents and the public and there are still no published national standards for hospitals.
The Avon Coroner did not make a prevention of future deaths report (1) because the Trust had made changes since Sean’s death.
Parents and the public have been given little information about the changes. University Hospitals Bristol says that it has designated some beds as “High Dependency” and claims to have recruited more nurses. Whether these changes are anything approaching nationally recognised standards of High Dependency provision is kept secret from the public.
In 2001 an expert advisory group produced this guidance on High Dependency for the Department of Health.
Bristol’s “High Dependency” seems to fall well short of even these requirements which are over twelve years old. Does Bristol have a lead for High Dependency Care? (paragraphs 17,18,19). Does it have a programme of clinical audit and critical incident reporting (paragraph 20)? Has it sought advice in establishing its High Dependency Unit from the Paediatric Intensive Care Society (Paragraph 24)? Does it have proper nursing care (paragraphs 25 to 31)? Is it properly equipped (paragraphs 32 to 37 and Annex A)?
One of Ms Voisin’s expert witnesses, Dr Ri Leisner, a haematology consultant from Great Ormond Street Hospital, said that the established national protocol is for anticoagulant levels to be checked at least every 24 hours, or as frequently as every eight hours when they are fluctuating (2). However Sean’s levels were not checked at least daily.
In June 2013 University Hospitals Bristol pulled out of Severn Pathology, a planned integration of pathology services with North Bristol NHS Trust. It was intended to deliver innovative, high quality pathology services. It is reasonable to suppose that Severn Pathology could be capable of delivering the standards of paediatric haematology analysis delivered by Great Ormond Street. Now it seems that all children using Bristol’s paediatric services will be deprived of the benefits of integrated pathology, not only because University Hospitals Bristol is no longer part of Severn Pathology, but because in April 2014 North Bristol NHS Trust is consigning its Paediatric Services (3) to University Hospitals Bristol.
The Avon Coroner’s decision not to make a prevention of further deaths report means that University Hospitals Bristol does not need to to provide information on the changes it has made following Sean’s death, such as a detailed description of its High Dependency facilities, its plans to provide safe, good quality care for the paediatric services to be transferred from Frenchay, and the extent to which its paediatric services meet recognised national standards. This seems to us to be a missed opportunity to reduce the risk of other children suffering and dying.
In April 2013, the NHS England Medical Director, Professor Sir Bruce Keogh said: “People undertaking surgical and other procedures in our NHS have a duty to describe what they do and define how well they do it. Otherwise, I think they forfeit some of their professionalism. This applies both to individuals and to organisations.”
Thirteen years after the Kennedy Inquiry, the Bristol Royal Hospital for Children will not describe what it does and how well it does it.
The South West Whistleblowers Health Action Group, three of whom are public members of University Hospitals Bristol NHS Foundation Trust, wish to pay tribute to the families of Sean Turner and Luke Jenkins for their courage, dignity and persistence in seeking answers about what happened to their sons. Had they not done so University Hospitals Bristol would have carried on, in the words of one of its governors, to “cut corners”.
© South West Whistleblowers Health Action Group 2014