A schoolboy with sickle cell disease died after a junior doctor ignored instructions from his consultant to carry out a blood test, an inquest has heard, reports dailymail.co.uk.
Emmanuel Akinmuyiwa, seven, from Tyseley, collapsed and died during a blood transfusion after staff ‘missed opportunities’ to save his life.
The boy suffered a cardiac arrest during the transfusion at Heartlands Hospital, Birmingham. It was carried out on 11 February, four days after the youngster was admitted to hospital.
But the coroner said that blood tests should have been carried out much earlier. If they were, it would have shown a transfusion was required far sooner – perhaps even on the day he arrived.
Instead, there was ‘insufficient understanding’ of the boy’s condition and a ‘lack of urgency’ before any action was taken.
The schoolboy suffered from sickle cell disease, a hereditary disorder that can cause red blood cells to mutate and restrict blood flow, Birmingham Coroner’s Court was told.
The condition was spotted by a GP who referred him to the hospital.
After he was admitted, Dr Helen Goodyear, a consultant paediatrician, set up a five-point treatment plan in which she asked for his haemoglobin, or hb, levels to be monitored.
That meant taking blood tests to ensure it was still at a healthy level. If the figure fell below five, it would show a definite need for a transfusion, Dr Goodyear told the court.
But her direct instructions were ignored by Heartlands staff, the court heard. The inquest heard how a junior doctor failed to take the tests when covering the weekend shift.
It was only when another doctor took over four days later that a blood test was taken and a transfusion was finally requested. The doctor found the blood had clotted.
After the request, there was still a four-hour wait for the correct blood type to arrive. The hb level was at just 2.7 grams when the transfusion was eventually performed.
Dr Goodyear said she was ‘horrified’ when she learnt her treatment plan had not been followed through by a junior doctor without consultation.
Senior Coroner Louise Hunt gave the cause of death as cardiac failure caused by severe anaemia due to sickle cell disease.
Mrs Hunt said: ”In my conclusion I do find a gross failure in not doing the blood test on the tenth (of February) when there was a clear clinical need and a clear direction to do so. There were other failures – to provide a transfusion on either the eighth, ninth or tenth… a failure by all staff to not recognise they had insufficient understanding of this condition and an appreciation of this very serious condition.’
Mrs Hunt ordered for a report to be sent to Clinical Commissioning Groups in the West Midlands and NHS England to ensure all trusts were better placed to treat patients with sickle cell disease.
Emmanuel’s father Oluwasemilogo wrote a letter of complaint to Heartlands and spoke of his loss in a written statement read out in court.
”The whole experience was very traumatic for us,” he said.
”He was our youngest child and only son. We had been trying for another child since 1997 and had to wait until 2005. We moved to the UK in 2006 to give our children a better life. ‘It’s impossible for us to have another child now due to my wife’s age. We are still struggling to come to terms with it and have constant recollections of his pain.”
Emmanuel was admitted to hospital complaining of a fever, leg pains and dizziness.
His healthy hb ‘base’ level was 8.5 grams per deciliter of whole blood, but it dropped to 5.7 grams shortly after his admission. It was at just 2.7 grams when the transfusion was eventually performed.
Dr Sarah Wilson, a consultant haematologist at Birmingham Children’s Hospital, which had been approached for advice on Emmanuel’s treatment, said transfusions should be performed when a patient’s hb count is more than two grams below their base level.