Missed opportunities to treat two-year-old child

What happened

Mr A's two year old son, C, had Down's Syndrome and suffered from leukaemia. He was admitted to hospital for treatment and had the first of four planned courses of chemotherapy. After this, doctors were keen to operate on C to see if the chemotherapy had worked. But the operation was delayed because of C's repeated infections. Eventually a doctor decided C was fit enough to have an anaesthetic and the operation took place in summer 2012.

C deteriorated over the next three hours and suffered a cardiac arrest (when the heart malfunctions and suddenly stops beating). After this, doctors treated him in intensive care for several weeks and gave him controlled antibiotics. A specialist pharmacy unit prepared the antibiotics, but prepared two doses at five times the dose prescribed. Doctors injected C with the antibiotics and this affected his kidney function, but he recovered from this over time. Doctors could not continue with C's planned chemotherapy course because of his cardiac arrest and damage to his heart.

C died at home in spring 2013. Mr A said he and his wife suffered unnecessary distress because of the Trust's failure to prevent C's cardiac arrest. They believe that because of this C could not continue with chemotherapy and this reduced his chances of recovery. Mr A was also angry about his son being given too much controlled antibiotic.

What we found

We partly upheld this case. The doctor who assessed C did not consider all the facts when he decided that C was fit enough for an anaesthetic. Specifically, he missed that C had been ill during the previous 12 hours. After the operation, nurses monitored him, but they did not escalate concerns to more senior staff when he began to deteriorate. This meant doctors missed several opportunities to treat him

When doctors did treat him, they gave C opiate medication and shortly afterwards he had a cardiac arrest.

We could not say that the cardiac arrest was avoidable, as it was possible C already had cardiac damage that caused the arrest, but a respiratory cause related to the anaesthetic and made worse by opiateswas also possible.

Mr A would never know if adequate assessment, or prompt response to C's deterioration, could have prevented his son's cardiac arrest. However, the subsequent decision to suspend his chemotherapy was correct, given the heart damage that C had suffered.

The Trust had fully accepted that doctors had given C overdoses of antibiotic and investigated the causes of this before Mr A complained to us. It put together a robust action plan to prevent the same thing happening again, which we found was adequate and sufficient.

Putting it right

The Trust acknowledged and apologised for its failings. We recommended it pay Mr A £5,000 and prepare an action plan to make sure that staff learned from the complaint.