11:09AM, Thursday 27 April 2017
Wexham Park Hospital
An apology has been made to the family of a four-year-old boy who died at Wexham Park Hospital.
A four-day inquest at Reading Town Hall into the death of Ghulam Mustafah Akhtar, of Cornwall Close, Maidenhead, started on Monday.
The inquest heard how, on December 21, 2012, Mustafah, as he was known, was brought into the hospital with a high temperature and pain in his right shoulder. He stayed in hospital with his grandmother overnight as his mother was also in hospital, having her third child.
By the time his father, Safdar Akhtar, returned the next day the boy’s condition had deteriorated and he was being resuscitated.
He died shortly after 9am following a cardiac arrest brought on by septic shock.
On Tuesday, coroner Peter Bedford heard that junior doctor Christopher Partner had mistakenly prescribed the wrong antibiotics to Mustafah.
In the end, the medicine was not available so it was not given to the child.
Dr Partner said it had been a busy night and he could not remember whether a nurse had escalated concerns about the child’s condition.
The coroner heard several opportunities were missed to escalate concerns.
Dr Partner was pressed by Shannon Eastwood, the Akhtar family’s lawyer, on why Mustafah’s worsening condition was not picked up, something he described as ‘passing the baton’.
Yesterday (Wednesday), consultant paediatrician Dr Kanaga Sinnathuray told the inquest that, after seeking advice from final year registrar, Dr Emma Fitzsimons, that Mustafah was not in septic shock, he did not examine the child.
He said: “I have to put my hand up and apologise to the family of Mustafah because I should have gone and seen this child.”
He added rules have changed since 2014 meaning a child who is admitted to the ward should be seen by a consultant within 14 hours.
On behalf of the family, Mr Eastwood thanked Dr Sinnathuray for his apology which ‘took courage’.
The inquest also heard from agency nurse Betty Ibekanma who said she became concerned about the child’s condition when she felt his feet were going cold and called Dr Partner, adding: “I would have loved to observe him more if I had the time and opportunity.”
She added that she was unable to escalate to charge nurse Steven Grimbleby, which he and his lawyer Scott Ivill dispute, saying they spoke ‘about four times’ during the shift.
After giving evidence the nurse was comforted by a member of Mustafah’s family.
This morning, Mr Bedford described how a 'gross failure' to provide basic medical attention contributed to the death of Mustafah.
In his conclusion at Reading Town Hall, the coroner said the four-year-old died of natural causes but only as a result of the neglect he received.
Mr Bedford said that throughout the boy's admission there were several failures and delays, including a failure to monitor his condition adequately, poor communication between staff, and a failure to identify and recognise the seriousness of Mustafah’s deteriorating illness.
He said: “On the balance of probabilities had an appropriate package of care been administered earlier it is likely it would have prevented the death of Mustafah.”
With regards to recommending a review into the systems and practices at the trust, Mr Bedford said he was happy with a report he had been provided with during his investigation, adding: “I do not believe it necessary to recommend a review.
“Lessons have been learned and I see changes which I believe will help make sure it doesn’t happen to another child in the future.”
UPDATE Friday, April 28, 10.30am:
The Frimley Health NHS Foundation Trust, which took over Wexham Park Hospital in 2014, has released the following statement:
"We are very sorry for the inadequate care that we gave to Mustafah in 2012.
"Following his death we carried out a thorough investigation which recognised we could have done more. As a result we made a number of changes in practice. For example:
- We put measures in place to ensure all children are reviewed more promptly by a paediatrician
- Improvements were made to the process for administering antibiotics within the right time frame
- We have increased awareness of warning signs when a child patient is deteriorating, including patients with suspected sepsis.
- We put measures in place to ensure that a child is examined by a doctor when they show signs of deterioration.
"We are grateful that the coroner acknowledged that following our investigation the trust has taken steps to address concerns and that this will help ensure the same opportunities are not missed in future."
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