Royal Alex 'failures' led to child's death

9:53am Thursday 16th October 2008

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A hospital is under investigation after catastrophic failures led to a little girl’s death.

The parents of 20-month Indya Trevelyan broke down as a damning verdict was delivered at the end of a four-day inquest.

“Losing our beloved daughter is devastating – discovering that her death was preventable is unbearable,” mother Sian, 37, said.

Medical bosses say they will delay a decision on whether anyone at the Royal Alexandra Children’s Hospital in Brighton will be sacked or suspended until the end of an independent review.

The toddler was suffering from croup, a common childhood infection, but died after a medical procedure went wrong.

Deputy coroner John Hooper recorded a verdict of medical misadventure.

Indya’s parents Sian, who is heavily pregnant, and Nigel Trevelyan, 43, said they believed it was the doctors’ failure to treat the cough early enough that led to Indya needing a life-threatening operation and condemned their treatment of her as “careless”.

The toddler was admitted to hospital with a cough on April 14 but three days later she needed an emergency tracheostomy, an operation that is usually only carried out by specialist London hospitals.

Mr Trevelyan, from Pease Pottage, near Crawley, said: “They had three days to move her to London but they left it until there was no alternative but to carry it out in Brighton.”

The procedure appeared to have been a success and the surgeons left Indya in the care of consultant anaesthetist David Campbell. He had never managed the procedure alone before.

Her breathing tube became dislodged and she suffered a cardio-respiratory arrest.

An initial investigation by the Brighton and Sussex University Hospitals NHS Trust concluded that Indya’s death was “preventable”. The deputy coroner told Indya’s parents: “You have lost a beautiful daughter. I can only offer you my greatest sympathy.”

He criticised the hospital for leaving Dr Campbell to manage Indya alone despite the fact he had little experience of the procedure.

Dr Campbell was also not told about crucial stay sutures the surgeons had used to keep Indya’s tube in place.

It is believed knowledge of the sutures might have helped Dr Campbell reinsert the breathing equipment after it became dislodged.

Instead there was a sixminute wait for a surgeon to arrive by which time Indya had suffered severe oxygen deprivation.

Mr Hooper said: “None of the consultants thought to ask Dr Campbell if he knew about the stay sutures and their purpose, or to tell him what they were there for before leaving Dr Campbell with any eventuality that might arise during the post-operative period. It would have been helpful if at least one person had stayed.

He was left in an impossible situation.”

He thanked Dr Campbell for his “honesty and frankness”.

Earlier in the inquest Dr Campbell described his surprise when he realised the usual neck ties used to keep tracheostomy tubes in place were not there.

He said they had been used in every tracheostomy he had seen in his career and described their absence as “extraordinary”.

The decision not to use the tie was made by consultant surgeon Dr Tony McGilligan who told the inquest that the ties often become soiled and he was concerned that the tube may be disrupted if staff tried to change it.

Mr Hooper said: “It is not for me to question his clinical judgement. That may be a matter for another court.”

An independent review into the hospital’s role in Indya’s death has now been set up.

Matthew Fletcher, medical director of Brighton and Sussex University Hospital NHS Trust, described it as a “catastrophic event” and told The Argus: “All of our staff have been profoundly affected by what’s happened. We are calling in independent experts to determine what action needs to be taken.

“We need to make sure communication between doctors is watertight so something like this never happens again.

“The planning of the operation was meticulous and it went very well. It was what happened after that that needs to be examined.”

Mr Trevelyan said: “It is almost six months since Indya’s life was taken away through carelessness, poor communication and inadequate training. Little has changed in that period and other children’s lives have been put at risk.

“We trusted the hospital with the most precious thing in our lives and they let us down. She was a normal, strong, healthy and extremely active child who developed a common childhood infection.

“She was kept in hospital untreated until it became so bad that an emergency tracheostomy was needed.

“This was then carried out by a hospital with little experience and no guidelines for the procedure. After the operation Indya was left in the care of a doctor who was unaware of a simple procedure to replace the tracheostomy tube if it became displaced. It did and she died as a result.”