Death of baby from hyperinsulinaemic hypoglycaemia prompts safety upgrade at Barts trust
BMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k1370 (Published 22 March 2018)Cite this as: BMJ 2018;360:k1370- Clare Dyer
A coroner has sent a report intended to prevent future deaths to the chief medical officer for Barts Health NHS Trust after a newborn baby boy died from undiagnosed low blood sugar levels.
Caliel Smith-Kwami was born in July 2017 and had a hypoglycaemic attack 28 hours later. He was admitted to the Royal London Hospital in east London, part of Barts Health, and tests were taken to determine the cause of the hypoglycaemia. But he was discharged from hospital before the results came back.
Insulin test results had not come back because a laboratory machine had a fault. Laboratory staff had not informed clinicians and they had failed to follow up the results.
Smith-Kwami was discharged on 2 August and died on 17 August from persistent neonatal hyperinsulinaemic hypoglycaemia.
At the inquest into his death, senior coroner Nadia Persaud said that the baby would probably have survived if doctors had been able to diagnose his condition. In January she sent Barts’ chief medical officer Alistair Chesser a regulation 28 report, which coroners have a duty to send if an inquest reveals information that could be used to prevent future deaths. She asked him to reply by 20 March, outlining the steps he proposed to take in response.
The laboratory results “should have been chased and received before discharge,” said Persaud. “Had they been received it is likely that Caliel would have undergone further investigation, monitoring, and treatment by a specialist team.”
Evidence given at the inquest also revealed that the results of his amino acid profile, which raised the possibility of hyperinsulinism, were sent to the electronic record system on 9 August, but it did not appear that any clinician was aware of the results before Smith-Kwami died. The consultant in charge of his care told the inquest that there was no system in place with the electronic system for highlighting to clinical staff that results were ready. Previously, clinicians would have got a paper result “but this notification has now been lost,” the coroner said.
She added that a ketone test might have helped with diagnosis but no witness at the inquest had been able to confirm whether the bedside ketone test was available within Barts Health.
A spokesperson for Barts Health told The BMJ that the trust had responded to the coroner’s letter. He added, “We apologise unreservedly for the distress caused to Ms Smith and her family as a result of failings in the care provided to Caliel. We are determined to learn from what happened, and have made many changes to prevent reoccurrence.
“Our laboratory systems have been fully upgraded and reporting systems updated to make all safe and reliable. In addition, all important and relevant test results are now reviewed by the clinical team before babies are discharged from hospital, and we are reviewing whether ward based tests for ketones might further improve safety.”
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