Swift and competent treatment could have saved post-op baby, says parents

http://www.theguardian.com/uk-news/2015/jan/09/lacey-marie-poton-inquest-verdict-parents

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The parents of a four-month-old baby who died after being discharged from hospital following a heart operation have said they believe the child would still be alive had she been treated “swiftly and competently” after she fell ill at home.

An inquest heard that Lacey-Marie Poton, who was born with complex congenital heart disease and Down’s syndrome, was discharged the day after undergoing an operation at Bristol Royal hospital for children, despite her mother’s concerns that she was not ready to leave.

She fell ill soon after arriving home and her parents took her back to the hospital where she was judged to have a stomach complaint and sent home again.

Her parents called an ambulance when Lacey-Marie went into a suspected cardiac arrest, but the crew that attended did not realise she had a “time-critical” condition and did not use their blue light to get her to back to hospital or warn staff they were on the way. Lacey-Marie died in her mother’s arms four hours after arriving back in hospital.

The inquest was the latest in a series involving children who have died after being treated for heart conditions at the hospital. Up to 10 families are believed to be taking legal action over deaths there, and an inquiry is under way.

Following the coroner’s narrative verdict, Lacey-Marie’s mother, Emma Norley, 21, and father, Jhonny Poton, from Bristol, said they still had unanswered questions.

“We can only hope that this experience helps ensure that children receive better care at Bristol in the future. We are convinced that she would still be with us had she been treated swiftly and competently,” they said.

“The unit’s patient safety record during the period of our daughter’s treatment continues to be a concern and we know that this is something that the other families who lost children at Bristol during this time are desperate to know more about.”

The Avon coroner Maria Voisin said the child’s deterioration remained unexplained. She said: “On 25 July she became extremely unwell and was taken by ambulance to hospital where she died. The cause of her acute deterioration which led to her death is not known.”

Tatjana Rjabova, a paediatric cardiologist, told the inquest she believed the baby had gastroenteritis after examining her when she first returned to hospital. “Mum was happy to try Dioralyte [a rehydration medicine] and go home if that was successful,” she said. “I went over the plans with A&E staff. I said she could go home if she looked well and mum was happy, and if not she should be admitted.”

Paramedic Nicholas Stock said using blue lights on the journey to hospital would have made a difference. He said: “We didn’t have a formal discussion of how she would be transferred to hospital and we just left. I feel I was probably a bit blinkered and I didn’t raise the issue of whether we would drive with blue lights or not. We arrived at the hospital 22 minutes later.

“A patient with cardiac history with a query cardiac arrest that is pale and floppy should be blue-lighted. I appreciate there has been talk that blue lights wouldn’t have made much of a difference but they would have made some difference, so that should have been done.”

A spokesperson for University Hospitals Bristol NHS Foundation Trust said: “Lacey-Marie was diagnosed before birth with complex congenital heart disease and was treated several times at both St Michael’s hospital and the Bristol Royal hospital for children.

“Shortly before she died at the age of four months, Lacey-Marie underwent a cardiology procedure and was discharged home the next day after a thorough review by clinical staff. She returned to the emergency department later that day suffering from the symptoms of gastroenteritis but was not suffering from any complications as a result of her cardiac condition. After comprehensive clinical assessment and observation, clinical staff judged there was no need to admit her to hospital and she was discharged home.

“The coroner’s independent conclusion is that the cause of Lacey-Marie’s subsequent sudden deterioration is unknown but she made no criticisms of the care Lacey-Marie received at the Bristol children’s hospital. We would like to reiterate our deepest condolences to her family.”

A spokesman for South Western Ambulance Service NHS foundation trust said it was “very sorry that some elements of the care did not meet the high standards expected”.

He said: “Whilst it is exceptionally rare for such an incident to occur, the trust has to ensure that all of our clinicians meet the high standards expected.”