Vital improvements are hoped to be made to the triage process and in how patients are handled when there are several different doctors involved in their care, in a bid to ensure better consistency and continuity.
The move comes after the inquest of Maryama Hussein (pictured right), who tragically passed away at the hospital in October 2021 after developing acute disseminated encephalomyelitis (ADEM).
Maryama’s parents Juweriya Abdalle and Mohamoud Hussein, were represented at the inquest today by Counsel instructed by Sharon Banga of Shoosmiths.
Maryama’s mother described her daughter as a “kind, caring and special child who was creative and made friends easily”. She added that she was “very loved and missed by her family”.
The hearing followed an internal investigation by the hospital into Maryama’s treatment which highlighted failures in the triage system, the ICU admission system, and delays in seizure control.
A finding of natural causes was returned by Louise Hunt, HM Coroner for the city of Birmingham and Solihull, who ruled Maryama’s cause of death as “cerebral oedema secondary to ADEM”.
The coroner ruled that it was the severity of Maryama’s condition (ADEM) that caused her death as opposed to the errors identified in the trust investigation report, but upheld the three main areas of concern, as previously identified in the internal investigation report.
These were:
- Flaws in the emergency triage process which was due to volume of patients and part of a recognised national issue. Maryama should have been referred from triage earlier. In total she experienced a delay of 105 minutes.
- There was a delay in admission to the paediatric intensive care unit (PICU) This was due to the operation of a shared care system, which left it open for there to be a difference of opinion between clinicians about referrals into PICU with no one clinician accepting full responsibility for decisions made. The way in which different doctors assess patients’ needs improvement and the idea of having a consultant to gatekeep the PICU admissions process was identified by the trust (to ensure patients don’t get incorrectly assessed).
- There was a delay in seizure control as Maryama’s seizures were incorrectly interpreted by her clinicians. This contributed to the delay in her admission to PICU.
Shoosmiths’ Sharon Banga said today: “We welcome the above acknowledgement of failings in care but will be closely considering Maryama’s cause of death with our own experts and commissioning an independent report.
“We will be continuing with our investigations given the severity of the errors and the changes to practices and procedures that are being considered by the trust at the moment. We hope that these changes will prevent a similar outcome for another family.”
The hearing heard how Maryama had been previously fit and well and a happy, sociable, little girl, when she started to vomit and developed a fever and headache. The family attempted to get an appointment with their GP surgery, finally seeing a doctor despite being told that she could not be admitted to the surgery because her high temperature (the reason for their concern) might indicate Covid-19.
Maryama was admitted to the Emergency Department of Birmingham Children’s Hospital on 29 September 2021 displaying all the previous symptoms but also bouts of unconsciousness and seizures. There was a delay incurred in her initial triage. She was eventually treated for acute disseminated encephalomyelitis (ADEM) and given antibiotics to cover the possibility of bacterial infection of the central nervous system, which presents with similar symptoms.
Despite this, the following day her condition had deteriorated with further seizures and bouts of unconsciousness. Those symptoms seemed to abate for a while but recommenced in the early hours of 01 October 2021. It took another full day for Maryama to be transferred to the Intensive Care Unit (ICU). Flaws have been identified in the hospital use of their anti-seizure pathway and treatment.
On 08 October 2021, her parents Juweriya Abdalle and Mohamoud Hussein had a meeting with the hospital to discuss their concerns and were told that an internal investigation would be performed because of the delay in admitting Maryama to ICU. On 12 October 2021, shortly after an unsuccessful attempt to perform a brain stem test, Maryama was pronounced brain dead, and her devastated parents gave their consent for life support to be terminated.
The internal investigation into Maryama’s treatment highlighted failures in the triage system, the ICU admission system and delays in seizure control.
External coverage
BBC News | Birmingham treatment delays did not contribute to girl's death
Birmingham mail | Dad's loving tribute to daughter, 5, after 'tummy bug' turned out to be fatal brain condition
Disclaimer
This information is for educational purposes only and does not constitute legal advice. It is recommended that specific professional advice is sought before acting on any of the information given. © Shoosmiths LLP 2024
