Hudgell Solicitors is supporting the family of a seven-year-old boy whose death at London’s Portland Hospital is being investigated after intensive care staff removed vital equipment used to monitor his breathing levels.
James Dwerryhouse – who suffered from sleep apnoea (which causes potentially life-threatening stoppages in breathing when asleep) – was found unresponsive in his bed by night staff after his monitoring equipment had been switched off and not turned back on for close to three hours.
Despite emergency attempts to save him, James suffered an irreversible hypoxic brain injury and died after his life-support was withdrawn the following day.
A Serious Incident Report (SIR) into his death has confirmed eight nursing staff were on duty in the Paediatric Intensive Care Unit (PICU) of the hospital on August 25, 2016. There was a mix of direct employees and bank and agency nurses caring for six patients, four less than capacity.
However, conflicting accounts of what happened that night have so far been given as part of the ongoing investigation, which has been passed to the Coroner, the Metropolitan Police Service, the Care Quality Commission (CQC), and Medical Advisory Committee for further consideration.
The Serious Incident Report (SIR) revealed staff;
- Took the decision to remove the monitoring equipment at 1.15am without consulting a more senior member of staff.
- Had breaks during the night shift which were longer than hospital rules permitted and failed to formally complete and document handovers of their responsibilities.
- Failed to properly document their observations of James throughout the night.
- Immediately turned off sounding alarms when reconnecting James’ monitoring equipment at 3.58am.
- May have taken 20 minutes to call cardiac arrest teams to come to James’ aid.
James number of health conditions, but had a happy life and was ‘cheeky and funny’
James battled a number of health conditions, including having to be fed through a tube, bowel problems, epilepsy and hearing and sight impairment, but was described by his family as a ‘cheeky, funny, happy and sometimes mischievous boy’, like most other children of his age.
He had successfully come through the elective formation of a colostomy at the hospital, which had been arranged to improve his bowel management and help ensure he was better prepared for moving into a new class at school.
James had been fine following his operation, enjoying a Facetime session with his brothers and sisters from his hospital bed, and was in good spirits when his father, John, left his beside in the early hours.
Just hours later however, James’ parents were call back to hospital and told their son was unlikely to recover. He was transferred to the Treehouse Hospice in Suffolk, where he died the following day – just two days after his successful operation.
‘Further serious questions need asking of all involved at hospital’ – Rosamund Rhodes Kemp
James’ family are launching legal action against HCA Healthcare UK, owners the Portland Hospital, through Hudgell Solicitors.
Solicitor Rosamund Rhodes-Kemp says ‘many further serious questions now need asking of all involved in caring for James at the hospital.’
An inquest is still to be held, and Mrs Rhodes-Kemp said: “What cannot be disputed in this case is that a huge, unforgivable error was made in that James’ monitoring equipment was turned off when it should have remained on at all times, that is after all why he was in Paediatric Intensive Care post operatively.
“Had the equipment remained on, no matter what other things were happening that night on the intensive care unit, staff would have been immediately alerted to any danger.
“What is totally unacceptable is the lack of detail and clarity forthcoming so far with regard to the specifics of what happened that night. The unit was not understaffed, it was not over capacity, and therefore there seems to be no excuse for what happened.
“Conflicting accounts have been provided as to what exactly happened when James was found not breathing. This means it has yet to be made clear whether the alarm was raised immediately, or whether there was a 20 minute delay, which obviously could have had a big impact on James’s chances of survival.
“Further serious questions now need asking by the relevant authorities, of all those involved in caring for James at the hospital that night. Answers must be forthcoming.
“To leave a child who is in the intensive care unit because he has a known condition such as sleep apnoea unmonitored, and also show such a lapse attitude towards break lengths, handovers of care, and observations, is almost beyond belief.
“This is a tragic case. This family took their son to hospital for a straight forward operation which passed without issue. He then died simply because of failures in monitoring. ”
Family hope legal case will bring answers as to what happened
James’ mother, Marguerite, said:
It has been completely heart-breaking. James had health issues and needed a lot of health support in his life, but he was full of life, cheeky, funny, happy, and occasionally mischievous, like all little boys.
Only days earlier he’d been to a summer club and he’d been chasing around, up and down the slides and having a great time. He wasn’t a fragile boy at all, he wasn’t poorly, and he certainly wasn’t a boy who was at risk of dying.
Everybody loved him, from his school to those who supported his health. This was a routine operation, and the operation itself was a complete success. To then lose him simply because hospital staff haven’t cared for him and checked on him as they should is something we cannot accept and never will.
We still don’t know the full truth. We know the police have been looking into the matter, and now we also have solicitors acting on our behalf, so hopefully we will get there in the end. We need to for James.
Until now we’ve been very quiet and even people close to us have been unaware of how James was let down and why he died. People need to know though, and we need to know exactly what happened that night.
Incident report concluded root cause of death was removal of monitoring equipment
The SRI, concluded that the root cause of James’ death ‘appears to be the removal of vital signs monitoring between 1.15am and 3.58am, as this resulted in the inability to be alerted to a suspected deterioration in the child’s respiratory condition and reducing oxygen saturations.’
It concluded that lessons need to be learned, included not removing vital signs monitoring from a child in the PICU without specific medical input and approval, that staff breaks on the PICU should always follow the Hospital’s expectations in terms of duration and frequency, and that all handovers between staff should be clearly documented with timings.
The SRI also addressed claims that James’ family had at some point asked for the monitoring equipment being removed – something they deny – adding that in all cases ‘the clinical needs of the patient remain priority above parental wishes’ anyway.