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121. We sought advice from an Infectious Diseases Consultant (the Infectious

Diseases Consultant Adviser) on the Trust’s comments. She explained that when Sam first arrived at hospital, he had clear signs of being unwell, as both his heart rate and breathing rate were higher than they should have been. She said that Sam had clinical features of early shock (pale skin colour, raised heart rate, raised capillary refill time and reduced urine output). The Infectious Diseases Consultant Adviser also said that Sam had a blanching rash, which she said was very likely a toxin-mediated rash.

122. The Infectious Diseases Consultant Adviser said that the blood gases taken at 11.04pm confirmed that Sam’s circulation was compromised (he was in shock): his lactate levels were raised. She said that although

Sam’s rate of breathing was increased, his oxygen saturation levels were still quite high at 92%, and the partial pressure of carbon dioxide in his blood was normal. Therefore, she said that ‘both clinically and as evidenced by the blood gas he had

compensated shock’. 103 _{She added that}

Sam’s C-reactive protein levels, and a white cell count that was not raised, indicated that he had a significant bacterial infection. Therefore, by approximately 11.30pm, doctors should have been aware that:

‘Sam had a serious illness … [but] he did not have any irreversible process present. The clinical picture at this stage did not indicate a child who was inevitably going to die, however immediate antibiotic therapy, fluid therapy and respiratory support with regular observations, were indicated. Discussion with the regional paediatric intensive care unit was indicated to discuss the serious nature of Sam’s condition and management strategies.’

123. The Infectious Diseases Consultant Adviser explained that Sam should have had antibiotics by 11pm at the latest. The delay in giving him antibiotics allowed the infection to develop and to replicate in his blood stream; this allowed Sam’s shock to progress (as evidenced by the deteriorating blood gases at 1.39am) and the development of disseminated intravascular coagulation.104 _{The Infectious}

Diseases Consultant Adviser said that Sam also received inadequate fluid therapy, and he also did not receive the necessary

respiratory support. She said that Sam’s respiratory failure was reflected in the increasing amounts of oxygen he needed to maintain his oxygen saturation levels; and that at 1.39am, his blood gas analysis showed a rising pCO2 (the amount of carbon dioxide in the blood) level, despite an increased rate of breathing, which would usually have reduced the pCO2 levels. 124. By 12.20am, there were clear signs that

Sam was deteriorating (fast heart rate, high capillary refill time despite being given fluids), and doctors should have again sought advice from the regional paediatric intensive care unit, who would ‘likely have given advice on the following aspects of care:

• ‘Circulatory failure: aggressive fluid therapy, intensive monitoring, monitoring of urine output, a further blood gas analysis to assess the response of fluids. Escalation to intubation and ventilation with evidence of fluid resistant shock and commencement of inotrope therapy.

• ‘Respiratory support: assisted ventilation is likely to have been requested by 1am at the latest as Sam had signs of respiratory failure – very high respiratory rate, climbing pCO2, and increasing oxygen

requirements.

• ‘Antibiotic therapy: I consider it likely that had the paediatric intensive care unit been consulted on this

103 There are three stages of shock: compensated, decompensated, and irreversible. In compensated shock, a number of bodily systems are activated to restore blood flow. This results in a number of changes to a patient’s physiological observations, including a faster heartbeat. The patient in this stage of shock has very few symptoms, and treatment can completely halt any progression.

104 A condition in which blood clots form throughout the body’s small blood vessels, reducing or blocking the blood flow, which can damage the body’s organs. The increased clotting uses up platelets and clotting factors in the blood and this can result in internal and external bleeding.

case soon after admission; that they would have ensured that antibiotic therapy was started as a matter of urgency; and also widened the antibiotic cover to include other antibiotics that penetrate deep seated infections and treated the toxin release from iGAS. Furthermore, given the blanching rash and developing shock picture, consideration as to the early use of immunoglobulin to treat possible toxic shock syndrome may have been made.

• ‘Other treatments: in the face of the mildly deranged clotting (Sam’s blood was not clotting as it should

have been) and [vomiting blood]

in the picture of serious infection, consideration of the use of fresh

frozen plasma105 _{would have been}

made.’

125. In summary, the Infectious Diseases Consultant Adviser said that Sam was admitted looking very unwell. The Trust’s failure to treat Sam’s serious infection and escalate his care over the next five hours led to a cardiac arrest. ‘Cardiac arrests

[caused by] hypoxia (lack of oxygen in the blood) are the result of a period of decompensation. It is my opinion that after admission, Sam was allowed to

decompensate and this led to his death’.

She added:

‘Had antibiotics been given at 1.30am and admission to a paediatric intensive care unit taken place at that moment (i.e. there was a paediatric intensive care unit in the hospital), I consider that on the balance of probabilities Sam would have survived. However,

as he was in a district general hospital, it is likely that they would have been slower to get him intubated and start inotropes and his chances of survival therefore would have been reduced. I think it unlikely he would have survived. ‘If Sam had received antibiotics at 11pm and been referred to paediatric intensive care unit, it is my opinion that he would have survived. However, antibiotics alone would most likely not have been enough, in severe pneumonia’s such as this antibiotics often do not work very fast. In the first instance, antibiotics prevent the condition worsening, prior to an improvement being seen. I consider it very likely that he would have required ventilation to assist his cardiovascular and respiratory systems whilst the antibiotics treated the infection. At 11am, Sam did not have respiratory failure and the severe pneumonia was restricted to the right lung. With assisted ventilation, I do not think he would have suffered hypoxic arrest. ‘Broad spectrum antibiotic cover would have had an immediate effect on the bacteraemia and the progression of shock. Together with optimal fluid therapy, stabilisation or early reversal of shock would have improved his prognosis considerably … for every hour shock is present, the risk of death is doubled.

‘Had Sam been referred [to hospital]

at any time after he was seen by the Second GP at the Surgery, it is my opinion that with optimal management he would have survived.’

105 Can be used for patients with acute disseminated intravascular coagulation in the presence of bleeding and abnormal coagulation.

Annex E: The PCT’s final