Death of Toddler at Glasgow Hospital Could Have Been Prevented, Sheriff Finds
The death of a three-year-old boy at the Royal Hospital for Children in Glasgow could have been avoided if an abnormal blood test result had been addressed sooner, a sheriff has ruled.
Archie Donald passed away on 20 November 2019 after suffering from an infection. A fatal accident inquiry (FAI) held at Glasgow Sheriff Court examined the identification and treatment of the infection, delays in hospital admittance, and issues with record sharing.
The inquiry's determination identified deficiencies in working systems, including failures to adhere to relevant clinical guidelines and Archie's care plan, missed blood test results, and the absence of a post-clinic multidisciplinary review.
Background and Medical History
Archie, born on 22 July 2016, had congenital nephritic syndrome (CNS), necessitating ongoing medical treatment, including the removal of his left kidney in 2017. Due to his condition, he had regular outpatient appointments and multiple hospital admissions for illnesses.
In the month prior to his final admission, Archie attended hospital twice. On both occasions, clinical staff did not suspect the bacterial endocarditis infection that a post-mortem examination later identified as the cause of death.
Failure to Follow 'Anticipatory Care Plan'
During a routine outpatient appointment on 5 November 2019, a blood test revealed Archie's C-reactive protein (CRP) level was 98mg per litre, significantly above the normal range. CRP measures inflammation and is an indicator of infection.
Despite this elevated level, Archie was not assessed for infection, blood cultures were not taken, and he was allowed to return home.
In his determination, Sheriff Thomas Millar stated that Archie's death could "realistically" have been avoided if the elevated CRP level on 5 November had been acted upon.
"Had blood cultures been ordered, they would 'on balance' have tested positive for Enterococcus faecalis - a species of bacteria naturally found in the intestines that can cause serious infection if it spreads," the sheriff said.
This would likely have led to further investigations and appropriate antibiotic treatment.
The sheriff also noted a failure to follow the "appropriate guidelines and anticipatory care plan in place for Archie," which would have involved consultation with an infection specialist.
The inquiry heard that Archie had regularly elevated CRP levels between 8 October and 5 November, with the latter not documented on his discharge letter. The sheriff observed that the 5 November CRP levels would have been discussed at a subsequent post-clinic multidisciplinary team meeting, but this meeting was rescheduled.
Events Leading to Final Admission and Death
At his next outpatient appointment on the morning of 19 November, medical staff observed that Archie was "very pale" and had developed a heart murmur. Blood tests were taken, and he was admitted for a blood transfusion to address low haemoglobin levels, alongside investigations into the heart murmur.
Archie was admitted to a ward that evening, monitored regularly, underwent further tests, and received antibiotics. However, his condition deteriorated, and his mother, Caitlin Donald, pressed the emergency buzzer when Archie stopped breathing.
Despite resuscitation efforts, Archie was pronounced dead at 04:36 after suffering a heart attack. Samples from his intravenous line taken earlier that evening later tested positive for Enterococcus faecalis.
The 39-page judgement clarified that while the infection's source was unknown, it was not connected to Archie's attendances at the Royal Hospital for Children.
"For the avoidance of doubt, the source was not connected to Archie's attendances at the Royal Hospital for Children," the judgement stated.
Condolences and Family Background
Sheriff Millar expressed condolences to Archie's family, acknowledging the difficulty of the inquiry process for them.
"I would wish to express my condolences to Archie's family. Many family members sat through every day of the inquiry, which must have been difficult for them," Sheriff Millar said.
"His family had nursed Archie from birth through many hospital visits and cared for him very well.
"Archie was about to embark on another stage of his life with a kidney transplant planned in the near future, with a donation of a kidney from his father."
Official Responses
Following the determination's publication, Procurator Fiscal Andy Shanks of the Crown Office and Procurator Fiscal Service commented:
"The death of Archie Donald occurred in circumstances giving rise to significant public concern and as such a discretionary FAI was instructed.
"The sheriff's determination is detailed and notes a reasonable precaution that could have been taken to avoid Archie Donald's death.
"The FAI followed a thorough and comprehensive investigation by the procurator fiscal who ensured that the full facts and circumstances of Archie's death were presented in evidence."
A spokesperson for NHS Greater Glasgow and Clyde stated:
"Our deepest condolences remain with the family of Archie Donald and we are very sorry for their loss and the distress they have experienced.
"NHS Greater Glasgow and Clyde supported the FAI and we welcome Sheriff Millar's findings and the opportunity to learn from this case.
"The sheriff's determination acknowledges that all necessary changes have been implemented since Archie's death and, as a result, makes no recommendations."
