Report into death of St Mellons boy highlights bank holiday shortages at Bristol Children'sHospital
6:56pm Sunday 9th September 2012 in Gwent news
A BOY who went into hospital for heart surgery suffered cardiac arrest within a week and died partly due to Bank Holiday staff shortages, according to a report.
Luke Jenkins, seven, was expected to make a full recovery after his successful corrective surgery at Bristol Children's Hospital.
His grieving parents are angry and disgusted at what they claim is the lack of care before and on the day of their son's death.
Stephen Jenkins, 30, and wife Faye, 27, of St Mellons, were stunned by the contents of a report into the tragedy.
Put together by an investigative team at University Hospitals Bristol NHS Foundation Trust, it is called a root cause analysis (RCA).
What it identified amounts to a tragic catalogue of avoidable human errors which combined with fatal consequences for Luke on April 6.
Junior nursing staff lost vital time because they did not know where resuscitation equipment on Ward 32, where Luke was placed, was kept.
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.
The surgeon was on the scene within 19 minutes of receiving the emergency call, although the report does not say when it was made.
"On the 6th April when the patient deteriorated it was a bank holiday; although it is recognised that the resuscitation team arrived quickly,’’ the report states.
"The cardiac surgeon had responded from home and had the chest open within 19 minutes of the emergency call.’’ What is clear is that 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 of three corrective operations before undergoing the third.
He was initially put into intensive care after his successful operation but was transferred to Ward 32 after several days.
While staff numbers on the ward was set according to official guidance, low staff levels had been a problem for at least two years.
"A risk assessment identifying low and unsafe nurse staffing and high dependency patient acuity issues was developed following a high-risk incident in October 2010 remains outstanding,’’ the report states.
There have been eight separate patient safety incidents on the ward since January, two of those sparking "high-risk’’ investigations."
All eight were linked to problems of low staffing levels.
Other worrying factors include the resetting of potentially vital alarms on Luke's condition monitoring equipment after his arrival on Ward 32.
"The patient was frequently triggering the alarms on his monitoring equipment; and the family witnessed the alarms being reset to a lower threshold by the nursing staff to stop the alarms from being activated,’’ the report states.
"Triggering the alarms did not appear to trigger a medical review.’’ The 40-page report makes eight recommendations and draws a raft of conclusions based on the experience of Luke's tragic death.
But the child's parents claim the report fails to give a true picture of what really happened.
They claim there was a series of factual errors.
An assertion that Luke underwent an x-ray the day before his death is questioned in a letter sent in reply to the report.
"If he had had an X-ray they would have found what was wrong with him and he would still be here now,’’ said an emotional Mr Jenkins.
"But we were with him all day and we know that it never happened.’’ He said that the family intended to fight on until the full truth was revealed.
"There have been eight other incidents since January 2012. They cannot tell us who the people were but that should be made public,’’ Mr Jenkins said.
"We have written saying that we are not happy with the report because some of what is in it is not true.’’ He said one major problem was that nursing staff failed to listen to them when they were anxiously calling for help for Luke.
That view is supported by the report itself, which states: "Failure to listen to the 'voice of the patient' is recognised to be a major contributory factor in patient safety investigations.’’ However, it concluded: "The RCA team were unable to comment on whether listening to the family on this occasion would have changed the patient outcome.’’