Heart surgery boy died 'due to staff shortages'
BANK holiday staff shortages were partly to blame for the death of a seven-year-old boy at Bristol Children's Hospital, a report has found.
Luke Jenkins was expected to make a full recovery after successful corrective heart surgery at Bristol Children's Hospital. But an investigation found that a catalogue of avoidable errors led to the death of the Cardiff youngster on April 7.
Put together by an investigative team at University Hospitals Bristol NHS Foundation Trust, which runs the city centre hospital, the report found that junior nursing staff lost vital time because they did not know where to find resuscitation equipment on Ward 32, where Luke was placed. The emergency team was also unfamiliar with the equipment because cardiac arrest was rare in the ward environment.
The fact that Luke suffered a cardiac arrest on Good Friday meant that the duty surgeon was at home when he collapsed and had to be urgently called in to attend hospital, although he was treating Luke within 19 minutes.
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Luke's heart stopped for 43 minutes before he was resuscitated, after which he underwent exploratory surgery. He died the following day.
Luke was born with a congenital heart defect and had already had two other corrective operations.
He was initially put into intensive care but was transferred to Ward 32 after several days.
Low staff levels had been a problem on the ward for at least two years, the report found. A risk assessment identifying "low and unsafe" nurse staffing and high dependency patient monitoring following a high-risk incident in October 2010 had not been dealt with and there had been eight separate patient safety incidents on the ward since January, all of which were linked to problems of low staffing levels.
The report also found that alarms on Luke's monitoring equipment were re-set because Luke was frequently triggering them after his arrival on Ward 32.
"Triggering the alarms did not appear to trigger a medical review," the 40-page report said.
Luke's parents Stephen, 30, and 27-year-old Faye, say the report itself contains errors and questioned an assertion that he had undergone an x-ray the day before his death.
"If he had had an x-ray they would have found what was wrong with him and he would still be here now," said Mr Jenkins. "But we were with him all day and we know that it never happened.
"There have been eight other incidents since January 2012. They cannot tell us who the people were but that should be made public."
UH Bristol acting chief executive Deborah Lee said: "We extend our deepest sympathy to the family for the loss of their child. We are aware of their concerns about the care their child received and are investigating those concerns. We are in contact with the family. Incidents do occur in a complex specialty such as paediatric cardiac services, where we are caring for some of the sickest children in the region. Each incident, no matter how minor it may appear, is recorded, rigorously investigated and actions taken forward as part of our clinical governance process.
"We provide highly specialist care for children with a range of complex cardiac problems from South Wales and the South West and our reported cardiac outcomes are amongst the best in the UK."