Hospital apologises after drug mix up causes teenager's death

Reporter:

Jamie Bowman

A MAJOR children’s hospital has apologised to the family of a 15-year-old girl from Flintshire after she died following a catalogue of blunders made by staff while she was in their care.

Robyn Louise Ellson, of Brookside Crescent, Northop Hall, had been battling leukaemia but was in remission before she died following a severe reaction to chemotherapy treatment which clashed with her kidney dialysis.

An inquest held at Liverpool Coroner’s Court heard Robyn died on January 19, 2013 while she was a patient at the city’s Alder Hey Children’s Hospital.

During the proceedings, which were attended by Robyn’s parents, Garry and Debbie, Dr Mark Caswell, a consultant haematologist, described the former Hawarden High School pupil’s death as “a tragedy”.

“This was a huge shock to us all and a huge wake-up call,” said Dr Caswell.

“We are all devastated and we should have anticipated these problems.”

The inquest was told Robyn had been diagnosed with cancer in August 2012 and battled through gruelling rounds of chemotherapy after being transferred to Alder Hey from the Countess of Chester Hospital.

The leukaemia had caused chronic renal failure and as a result Robyn was put on “maintenance therapy” which saw her receive low doses of methotrexate while on dialysis.

On January 11, 2013 Robyn was readmitted to Alder Hey suffering from bleeding gums, skin blisters, headaches and nose bleeds.

Doctors established the teenager was having a toxic reaction to the dose of methotrexate which should not have been prescribed to someone suffering from renal failure.

“It was an unexpected reaction,” said Dr Caswell. “So few children suffer from renal failure that these were unexpected issues that we did not recognise. We are reliant on guidelines but this was something that we just don’t experience.”

Robyn’s condition deteriorated and after blood clots formed in her airway she suffered two cardiac arrests and died in the early hours of January 19.

The cause of death was given as asphyxiation as a result of a respiratory tract haemorrhage, methotrexate (oral chemotherapy drug) toxicity, renal failure and acute promyelocytic leukaemia (APL).

Area coroner Anita Bhardwaj criticised Alder Hey for a “series of issues” which had contributed to Robyn’s death, including “a failure to take account of (her) chronic renal condition” and “a failure to recognise a deterioration” in her condition.

A meeting held in December 2012 was described as “a missed opportunity” to discuss her condition and the coroner urged nurses to keep better notes of treatment and meetings.

“Robyn’s care and treatment was poor,” added Ms Bhardwaj who recorded a narrative verdict before offering her sympathies to the teenager’s family and friends.

Catherine Wardell, Alder Hey’s associate chief nurse for medicine, told the inquest systems had been overhauled.

“We are all devastated and wanted to put procedures in place so this doesn’t happen again,” she added.

A statement from Alder Hey Children’s NHS Foundation Trust said the trust “accepted failures were made” during Robyn’s treatment.

“We wish to pass on our sincere apologies and heartfelt sympathies to Robyn’s family at this difficult time,” a spokesman said.

“Robyn received treatment at Alder Hey between 2012 and early 2013. The trust accepted that failures were made in her care following a root cause analysis investigation in 2013.

“Immediately following Robyn’s death, actions were taken and embedded by the trust.

“This included retraining staff in a paediatric early warning tool which identifies a deteriorating patient.

“This has been further enhanced with a new electronic system of recording.

“In addition we have consistently been reviewing all the actions taken and our ongoing practice to ensure we continue to provide the highest standards of care.”

 

 

 

 

Email:

jamie.bowman@nwn.co.uk

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