Death of toddler could have been avoided, sheriff rules

The death of a three-year-old boy at a Glasgow hospital could have been avoided if an abnormal blood test result had been acted on sooner, a sheriff has ruled.

Archie Donald died at the Royal Hospital for Children in Glasgow on 20 November 2019 after suffering from an infection.

A fatal accident inquiry (FAI) into his death was held at Glasgow Sheriff Court and focused on the identification and treatment of the infection, the delay in admittance and record sharing.

The determination found defects in systems of working, including failures to follow relevant clinical guidance and Archie's care plan, missed blood test results, and the absence of a post-clinic multidisciplinary review.

Archie, who was born on 22 July 2016, suffered from congenital nephritic syndrome (CNS), which required him to have ongoing medical treatment, including the removal of his left kidney in 2017.

This meant he had regular outpatient appointments and had been admitted to hospital with illnesses on multiple occasions.

He attended hospital twice in the month leading up to his final admission and on both occasions, clinical staff did not suspect the bacterial endocarditis infection that a post-mortem examination later identified as the cause of death.

Failure to follow 'anticipatory care plan'

During a routine outpatient appointment on 5 November 2019, a blood test found Archie's C-reactive protein (CRP) level was 98mg per litre - well above the normal range.

CRP, which measures inflammation levels in the body, is an indicator of infection.

But the inquiry heard that Archie was not assessed for infection, his blood cultures were not taken and he was allowed to return home, despite the high level.

In his determination, Sheriff Thomas Millar said Archie's death could "realistically" have been avoided if his elevated CRP level on 5 November had been acted upon.

He said had blood cultures been ordered, they would "on balance" have tested positive for Enterococcus faecalis - a species of bacteria that is naturally found in the intestines and has the potential to cause a serious infection if it spreads to other areas of the body.

This would have likely prompted further investigations for appropriate antibiotic treatment to treat the infection, the sheriff added.

He also noted a failure to follow the "appropriate guidelines and anticipatory care plan in place for Archie", which would have led to a consultation with an infection specialist.

The determination also heard that Archie was regularly found to have elevated CRP levels between 8 October and 5 November, with the latter not noted on his discharge letter.

The sheriff said Archie's CRP levels on 5 November would have been raised at a subsequent post-clinic multi-disciplinary team meeting, but this meeting was rescheduled.

During his next outpatient appointment on the morning of 19 November, medical staff noticed Archie was "very pale" and he had developed a heart murmur.

Medical staff took blood tests and he was admitted for a blood transfusion to address low haemoglobin levels, as well as investigations into his heart murmur.

Archie was admitted to a ward that evening, checked regularly and given further tests, and nurses administered antibiotics.

But his condition worsened and the inquiry heard that his mother Caitlin Donald pressed the emergency buzzer as Archie had stopped breathing.

Efforts were made to save his life but he was pronounced dead at 04:36 having suffered a heart attack.

Samples from his intravenous line earlier that evening later tested positive for Enterococcus faecalis.

The 39-page judgement said that, while the source of the infection was unknown, "for the avoidance of doubt, the source was not connected to Archie's attendances at the Royal Hospital for Children".

"I would wish to express my condolences to Archie's family. Many family members sat through every day of the inquiry, which must have been difficult for them," Sherriff Millar said.

"His family had nursed Archie from birth through many hospital visits and cared for him very well.

"Archie was about to embark on another stage of his life with a kidney transplant planned in the near future, with a donation of a kidney from his father."

Following publication of the determination, Procurator Fiscal Andy Shanks for the Crown Office and Procurator Fiscal Service, said: "The death of Archie Donald occurred in circumstances giving rise to significant public concern and as such a discretionary FAI was instructed.

"The sheriff's determination is detailed and notes a reasonable precaution that could have been taken to avoid Archie Donald's death.

"The FAI followed a thorough and comprehensive investigation by the procurator fiscal who ensured that the full facts and circumstances of Archie's death were presented in evidence."

A spokesperson for NHS Greater Glasgow and Clyde said: "Our deepest condolences remain with the family of Archie Donald and we are very sorry for their loss and the distress they have experienced.

"NHS Greater Glasgow and Clyde supported the FAI and we welcome Sheriff Millar's findings and the opportunity to learn from this case.

"The sheriff's determination acknowledges that all necessary changes have been implemented since Archie's death and, as a result, makes no recommendations."