This case was reviewed by the PDRC – Medical in 2016 and illustrates the difficulties and challenges that can arise for health care practitioners when caring for paediatric patients.   

File  

2014-10891 (PDRC-2016-02)

Date of Death: October 8, 2014

Date of Birth:  January 16, 2013

Age: 20 months

Date of Review: March 2016

Sources Reviewed

1.    Coroner’s Investigation Statement (Form 3)

2.    Paramedic patient care records

3.    Provincial emergency referral service patient report

4.    Medical records from:

  • Children’s Hospital
    • Bridge call report
    • Bridge call recording
  • Hospital A
  • Hospital B
  • Family physician

5.    Report of Post Mortem Examination

Past Medical History

The decedent was a 20-month-old child with Trisomy 21 who lived with her parents. In the neonatal period, she had surgical intervention for duodenal atresia and aortic infantile coarctation. At six months of age, she had cardiac surgical repair of an atrio-ventricular septal defect (AVSD) at the children’s hospital. She developed chylothorax post operatively, however this responded to medical management. She was slow to gain weight requiring gastrostomy tube (G-tube) feeding. She had previous bilateral nasolacrimal duct obstruction probed by an Ophthalmologist.  Her family doctor supported her general medical care with cardiology care provided by cardiologists at the children’s hospital and another pediatric centre.

Terminal Events

The child was assessed by her family physician at about 09:00 hours on October 7, 2014 after presenting with a 24 hour history of cough and respiratory tract like illness.  She was afebrile with a temperature of 36.7°C. The child’s throat was red (3+) with normal ears and lymph nodes and a clear chest. There was no documentation of vital signs (blood pressure or pulse) or respiratory rate in the medical records relating to this visit. A diagnosis of upper respiratory tract infection was made and she was provided with a prescription of Amoxil. 

After return home, her condition deteriorated with development of shortness of breath and respiratory distress.  Her parents took her to Hospital A (a 34-bed healthcare facility) at approximately 20:55 hours on October 7, 2014.  She was assessed by the emergency room physician at 21:02 hours.  Documented vital signs included temperature of 38.9°C, tachypnea with a respiratory rate of 60 breaths/minute, heart rate (HR) 140 and blood pressure 128/78.  Her oxygen saturation was 91% in room air. She was noted as agitated and restless.  Examination demonstrated presence of intercostal and subcostal indrawing and decreased air entry bilaterally.  Few crackles and wheezes were heard on chest auscultation. 

Three doses of Ventolin and Atrovent were provided in succession followed by Pulmicort inhalation.  A chest X-ray was completed showing bilateral lung infiltrates with the right significant and worse than the left lung representative of fulminant pneumonia. Intravenous access was not able to be obtained precluding collection of blood for culture and other testing. Insertion of an intraosseous infusion needle was attempted, but this access was not achieved as fluid could not be infused. A dose of Clavulin was given via the G-tube followed by intramuscular injection of 1 gram of ceftriaxone.  Oxygen was provided via nasal prongs at 4-5 L/minute. Despite these interventions, the child remained mottled and cool.  Contact was made with the provincial emergency referral service who facilitated bridge discussion between Hospital A medical staff and the children’s hospital‘s Intensive Care Unit. 

The Hospital A treatment provider and children’s hospital bridge call staff discussed the case.  The call was initiated at 23:16 hours with request made by Hospital A emergency staff for transfer of the child to the children’s hospital.  On review of the bridge call recording, the major focus of the communication was lack of appropriate IV access. Concern about the seriousness of child’s condition and acuity was not apparent in post death review of the recording. There was no demonstrable urgency in the discussion despite the seriousness of the child’s clinical condition as demonstrated by the vital signs, physical examination findings and chest X-ray findings.

Staff at the children’s hospital made plans for initial assessment in their emergency department after transfer of the child. The discussion resulted in decision to transfer the child from Hospital A to Hospital B (a 494-bed regional hospital) to expedite assessment and stabilization by a paediatric specialist. The children’s hospital Transport Team planned to attend Hospital B to facilitate transfer.  Air transfer was not available. Paramedic services were contacted by the children’s hospital Transport Team to indicate need for an ambulance to facilitate transfer from Hospital B.

Paramedics were accompanied by a general practitioner/anesthetist from Hospital A during land ambulance transfer of the child to Hospital B. The ambulance was requested at 23:49 hours and arrived at Hospital A at about 23:55 hours. Following assessment of the child, the ambulance departed at about 00:09 hours on October 8, 2014.  Two set of vital signs were recorded during the transfer to Hospital B.  The initial set was noted to have been taken around midnight with pulse rate of 140, respirations 60 breaths/minute, blood pressure 128/78 and oxygen saturation of 93% with supplemental oxygen.  The second set of vitals completed at 00:40 hours noted weak pulse of 140/minute, respiration was 60 breaths/minute, and oxygen saturation of 93%.  No additional blood pressure measurement was documented during the transfer. The child was described as pale. 

Review of incident reports prepared by the paramedics documented that prior to arrival at Hospital B, the child was being bagged by the accompanying physician.  There was no evidence of use of a cardiorespiratory monitor.  The child was noted to have asystole with absence of vital signs upon arrival at the Hospital B emergency department at 00:50 hours. 

CPR was immediately commenced with intraosseous fluid provided. Several doses of epinephrine and atropine were also provided during the unsuccessful resuscitation attempt. The child was pronounced deceased at 01:10 hours on October 8, 2014. 

Post Mortem Examination Findings

The child’s weight was 8 kg with height 68 cm; both below the third percentile. The previous areas of surgical intervention, i.e., coarctation, AVSD and duodenal atresia were all free of complication.

There was bilateral acute bronchopneumonia bilaterally, right worse than left. 

Polymerase Chain Reaction (PCR) testing from the lung was positive for enterovirus and rhinovirus.  Bacterial cultures from the post mortem blood and lung were negative and anti-mortem blood culture was not completed given the vascular access difficulties.  There was suggestion of patchy pulmonary arterial medial wall thickening and intimal fibrosis suggestive of pulmonary hypertension. There was a mild left ventricle outflow track stenosis. 

Cause of Death: Complications of Acute Bronchopneumonia

Contributing Factors:Trisomy 21, Congenital Heart Disease, Pulmonary hypertension

Manner:  Natural

Comments and Issues Raised

This child had a complicated past medical history including Trisomy 21 with surgical repair of duodenal atresia, infantile coarctation, and AVSD, in the first year of life. She had ongoing failure to thrive and was gastrostomy tube dependent for feeding.  Children with such medical history are intrinsically at higher risk for infections primarily respiratory, as well as aspiration. 

When seen by the family physician the day prior to death, the symptoms were suggestive of a respiratory illness.  While there was limited documentation, the child was noted to be afebrile without recording of the respiratory rate or other vital signs. The throat was documented to be red (3+). The working diagnosis was upper respiratory tract infection with Amoxil prescribed. She was likely in early stages of respiratory illness. 

Following return home, the child demonstrated deterioration in her respiratory status. She was taken to Hospital A in the evening. Intravascular access could not be obtained as the intraosseous needle was not functioning. Blood testing was not completed. It is unknown if capillary blood testing was available at Hospital A.  The child remained at Hospital A for about two hours prior to transfer by the paramedics during which her clinical status remained poor despite medical intervention. This was likely representative of fulminant pneumonia.    

Limited documentation was available or completed during the transport to the Hospital B.  Blood pressure was not recorded with the other vital signs documented at 00:40 hours during the transfer. It was not clear if there was a cardio-respiratory monitor present in the ambulance and used.  A physician accompanied the child during the transfer.  The physician was bagging the child as they arrived at Hospital B and the child was without vital signs upon entry into the emergency department. There was no documentation from the physician outlining the events during the transfer.  It may have been beneficial to intubate the child prior to transport.

The children’s hospital Transport Team had not departed as the paramedic service was unable to provide an ambulance. 

Recommendations

  1. Hospital A should consider conducting a lesson learned case review of the assessment and care of the child during the October 7-8, 2014 Emergency Department visit.  This review should include:
    • Physicians and nursing staff from the Department of Emergency Medicine, Anesthesiology and paediatric staff from the routinely assigned paediatric tertiary referral centre. 
    • Suggested areas for focus are:
      • Recognition, assessment and management of seriously ill high risk children including, but not limited to:
      • Approach to involvement of tertiary referral centre
      •  Anticipating when the trajectory of illness may indicate that it will exceed the capacity of the hospital
      • Clarity of communication of clinical presentation
    • Consideration of departmental Paediatric Advanced Life Support update education focusing upon:
      • methods of vascular access and fluid resuscitation
      • Approach to laboratory testing when intravenous access is not successful
      • Importance of regular collection and charting of a complete set of vital signs (including blood pressure)
      • Airway management in a child who has serious respiratory illness
  2. The children’s hospital Intensive Care Unit should consider conducting a lesson learned case review of the bridge call with focus on:
    • Approach to ascertainment of severity of illness to inform decision making
    • Decision making approach in developing a patient transfer plan.
    • Communication with Hospital B about the plan upon arrival of the child
  3. The Director of the Acute Care Transport Services (ACTS) at the children’s hospital should coordinate with paramedic services to undertake a joint review of the approach to availability of ambulance vehicles when required by the ACTS team.
  4. A copy of the case report should be shared with the Provincial Council on Maternal and Child Health as a case example of the challenges associated with transport of seriously ill paediatric patients.  
  5. The paramedic service for Hospital A should undertake a review of the care and management of the child during the transfer to Hospital B with focus upon:
    • The approach to patient care when there is a physician present with the patient including:
    • Paramedic presence with the patient
    • Continuous monitoring of a seriously ill child
    • Regular completion and documentation of vital signs
    • Documentation of clinical care and patient status