Six-year-old Jack Adcock had Down’s syndrome and a heart condition. In February 2011, he was admitted to Leicester Royal Infirmary with vomiting and diarrhoea. Eleven hours after being admitted to hospital, Jack died of a cardiac arrest.
The cause of his death was a heart attack caused by septic shock triggered by a virulent type of pneumonia. A jury found the treating doctor and a nurse guilty of manslaughter because Jack was “seriously neglected” in hospital.
Jack died because of the many errors made by hospital staff during a short but critical period of time.
What went wrong?
The doctor (a paediatric specialist) who saw Jack when he was first admitted, mixed him up with another boy. She confused Jack with another patient who had a “do not resuscitate” order. She called off Jack’s resuscitation treatment. The doctor only resumed treatment when a junior doctor pointed out the mistake.
Based on reports of the trial, and the earlier inquest, it is clear that there was a catalogue of errors leading up to the decision to stop Jack’s resuscitation:
- There was a mix up in the identity of patients on the ward
- Jack’s identity was not checked when a crucial major decision was made concerning life-saving treatment
- Proper account was not taken of Jack’s test results
- As a consequence, the preliminary incorrect diagnosis was not questioned
- Record keeping was poor
- Communication on the ward was poor
- The doctor was tired, on a 12 hour shift with no break
There is often a temptation to just blame the individuals involved. It is often as much, if not more, to do with faults in the system. These faults need to be addressed.
Could Jack’s death have been avoided?
This is always a difficult question when considering the treatment of a seriously ill child. In this case, the answer is yes.
The prosecution said that Jack’s death could have been avoided and that his death was caused because of “serious neglect” by the medical staff. This was on the basis that the medical staff failed to notice that his body was “shutting down” and that he was close to death.
The doctor and the nurse said that their actions would have made no difference to the outcome and that Jack would have died in any event. Was that true?
The prosecution did not agree with the views of the medical staff. Andrew Thomas QC said Jack’s condition had needlessly declined “to a point where…he was effectively beyond the point of no return.”
Paediatricain Dr Hadiza Bawa-Garba and agency nurse Isabel Amaro were both found guilty of manslaughter by gross negligence. So the jury decided that Jack’s death could have been prevented. This was by a majority verdict of 10 out of 12 jurors.
The question of whether Jack’s death could have been avoided was also considered at an inquest held a few years before the trial.
At the inquest into Jack’s death in July 2013, expert witness Dr Pearson (a consultant paediatric intensivist) told the Coroner he believed Jack would have survived had he been treated properly.
Dr Pearson was questioned by Coroner Catherine Mason and said he was “sure beyond reasonable doubt” that Jack would not have gone into cardiac arrest had he been treated properly.
Sorry seems to be the hardest word
After the jury’s verdict in November 2015, over 4 years after Jack died, Andrew Furlong, interim medical director at the University Hospitals of Leicester NHS Trust, said: “We cannot bring Jack back and under the circumstances saying sorry does not seem enough. Nevertheless, we are deeply sorry and would like to again send our condolences to the Adcock family.”
Repeating past tragedies
The NHS must learn lessons from previous failures and must try to prevent such deaths. Avoidable deaths have occurred since Jack died, and all possible steps must be taken to prevent them in the future.
As a parent of young children, it is hard to comprehend the severe emotional distress that this will cause to the mother and father. To lose a child is one thing, but to discover at an inquest or at a trial that your child should not have died is impossible to comprehend.
Disclaimer: The contents of this article are for the purposes of general awareness only. They do not purport to constitute legal or professional advice, and the law may have changed since this article was published. Readers should not act on the basis of the information included and should take appropriate professional advice on their own particular circumstances.