‘Opportunities missed’ to save eight-year-old boy’s life, inquest hears
- Credit: Archant
An eight-year-old boy’s life could have been saved were it not for a registrar’s “unacceptable” assessment, an inquest has heard.
Charlie Goodwin died at Addenbrooke’s Hospital, Cambridge, on September 6 last year after suffering several cardiac arrests.
It became clear during the final hours of Charlie’s life that he had an undiagnosed condition known as bowel malrotation, which manifests during the embryonic stage of life.
The Harleston youngster, who lived on Tudor Rose Way, ultimately died as a result of haemorrhagic shock and multiple organ failure.
Before being transferred to Addenbrooke’s, Charlie had been taken to Norfolk and Norwich University Hospital (NNUH) after experiencing severe abdominal pain.
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But surgical registrar, Sundeep Kisku, decided he did not require surgery and should continue to be monitored.
At the conclusion of a two-day inquest into Charlie’s death, senior staff from NNUH admitted sending Charlie to theatre earlier could have saved his life.
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Writing to Charlie’s parents, Erika Denton, medical director at NNUH, said: “The assessment made of Charlie by the registrar was not acceptable.
“It was a missed opportunity to discuss Charlie’s condition in a more urgent manor. There may have been an opportunity to save Charlie’s life.
“Charlie received sub-optimal care and it is my intention that we learn every lesson we can to ensure this does not occur again.”
Friday’s inquest opening heard football-mad Charlie was seen by his GP regarding abdominal distension in March 2019, and an X-ray in July revealed significant dilation of his bowels.
Doctors, however, could not identify the reason for his illness.
As he deteriorated, Charlie was admitted to hospital in early August, but his parents were told their son was a “medical mystery” and he was discharged.
A month later, on the evening of September 5, Charlie was admitted to hospital again with agonising pain.
At 11.30pm, paediatric registrar Dr Kazeem Omobolanle contacted on-call consultant paediatrician, Dr Caroline Kavanagh, stating she believed Charlie was a surgical case.
She told Dr Kavanagh that Charlie’s abdomen was distended and “tender”, and that he required an urgent operation. But Mr Kisku, the surgical registrar, instead decided it was “soft” and did not need surgery.
By 2am, Charlie’s condition had worsened and it was recommended a blood test was carried out prior to taking him to theatre.
But as blood was taken, he went into cardiac arrest and resuscitation took 11 minutes, before suffering a second which took half an hour.
At 4.42am, Charlie was finally stable enough for surgery, during which doctors discovered his malrotation and told his parents he needed to be transferred to Addenbrooke’s.
Upon arrival, on the afternoon of September 6, Charlie suffered two further cardiac arrests.
After a fifth arrest, Charlie’s parents were told their son would not survive another and would have no quality of life due to brain damage and multiple organ failure.
They made the “agonising” decision for no further resuscitation attempts to take place when he had a final arrest.
At Monday’s inquest, Dr Mary-Anne Morris, consultant paediatrician at NNUH, detailed action taken by the hospital to avoid similar tragedies following a report from the Royal College of Surgeons.
She said staff were being reminded of the importance of contacting consultants with serious concerns about patient welfare, while efforts are being made to increase overnight staffing.
“What we want to make sure is that, if there is a discrepancy, it is escalated to consultants and doesn’t get stuck between two registrars,” said Dr Morris.
“If Charlie had not had an arrest before going to theatre, his chances of surviving would have been much greater. The level of care we normally provide was not what Charlie got.”
Giving a narrative conclusion to the inquest, senior coroner for Norfolk, Jacqueline Lake, said Mr Kisku’s examination of Charlie had not been thorough enough.
She said a recording of proceedings would be sent to the General Medical Council, stating: “They may wish to investigate Mr Kisku’s evidence and his fitness to practise.”
But she praised NNUH’s response, adding: “The hospital has clearly taken Charlie’s death very seriously. They have undertaken an extensive review and I am heartened by the steps taken.”