Investigation Report Sets Out 12 Recommendations To Improve Care In Future

The distraught parents of a four-year-old autistic boy who died just two days after being discharged from Nottingham Children’s Hospital are taking legal action as they demand answers as to whether more could have been done to prevent their son’s death.

Harry Procko, who suffered with autism, was first referred to A&E at Nottingham Children’s Hospital on 20 June 2014 following a severe stomach bug but he was discharged the next day after doctors decided he didn’t need blood tests. He died two days later on 23 June. A blood test taken immediately before his death identified that his blood pH level was such that he had no chance of survival.

His parents, Richard Clements and Maria Procko, from Nottingham, have instructed specialist medical negligence lawyers at Irwin Mitchell to investigate the treatment Harry received in the days leading up to his death. The Nottingham University Hospitals NHS Trust, responsible for the Nottingham Children’s Hospital, has just released its High Level Investigation Report which is critical of the treatment Harry received. Expert lawyers, along with Harry’s family, are therefore calling for a swift resolution to the legal case.

The High Level Investigation Report found that there was a ‘missed opportunity to perform a blood test on Friday 20 June’ and states that, had there not been a failure to communicate the seriousness of Harry’s condition, his death may have been prevented.

The report highlighted two main failures:

• A lack of seamless emergency admission and good communication between different departments
• Inadequate guidance for staff when the optimal plan of care is not agreed with by the parent/carer.

The report sets out 12 recommendations including offering the family a chance to discuss its details and that they should receive an apology.

Adam Wright, a specialist medical negligence Solicitor at Irwin Mitchell representing the family said: “This is obviously a very difficult time for Harry’s parents and they are devastated by his death. They just want answers as to what went wrong and why so that lessons can be learnt to improve care for others in future. We hope the NHS Trust will work with us to resolve the case quickly and fairly in light of the findings of the published report.

“We are now working with the family to further investigate the events leading up to Harry’s death and while we welcome the Serious Incident Report it is vital that the words translate into actions and that where appropriate the recommendations are shared with the NHS across the country to ensure all relevant medical staff are aware of the issues raised.”

Harry’s father Richard, 48, is running a campaign calling for Hospital guidelines to be changed when dealing with children with special needs. While they were waiting on the hospital wards for Harry to be checked out he often became distressed because of his autism

He said: “We just thought Harry had a bad stomach bug but three days later he died leaving us all absolutely distraught.

“Harry was born with a hole in his heart which had been successfully treated so we know from his first few years of life the importance of getting the right treatment as soon as possible. This is why we sought medical attention and took him to the doctor.

“We were a bit taken aback on the Saturday when he was fully discharged as the day before they had said he needed several tests. We feel that more could and should have been done and the High Level Investigation Report has now proved that to be the case.

“We are grateful to the hospital for investigating this but there is still a long way to go before we are satisfied that all lessons have been learned from what happened to Harry. We still don’t know exactly what caused his death and we hope that the report is the starting point for change within the NHS in relation to dealing with this issue and in supporting the families of children with special needs.”

Harry was taken to his GP in June this year with a suspected stomach bug as he has symptoms such as diarrhoea, vomiting and stomach cramps. There was no improvement over the following two days so he was referred to A&E at the Nottingham Children’s Hospital with an accompanying letter from a GP.

The hospital assessed Harry as a category 2 patient, which suggests that he should be seen more urgently than someone coming in off the street, and he was found to be dehydrated. Doctors in A&E wanted to run blood tests and put him on a drip to rehydrate him, but when Harry was transferred to the Children’s Assessment Unit he was becoming distressed as the family were left waiting for hours. Because it did not appear that the tests or the drip were going to be carried out the same day, given the long period in which they had waited, his parents asked if they could take Harry home in order to allow him to get some rest, and to return the following morning, which the doctors agreed to.

The following day the doctor said Harry seemed better and he was discharged saying that a blood test and other investigations were no longer necessary. His condition remained the same throughout the next day but on Monday 23 June Harry collapsed and turned blue. He was rushed to hospital by ambulance. Resuscitation attempts were unsuccessful and Harry died. A blood test was carried out during Harry’s attempted resuscitation. 

The results of the blood test revealed that there were high levels of sodium in his blood, which is often seen in cases of severe dehydration and is understood to be quite common in young children with learning difficulties and special needs. The results of a peri-mortem suggest that Harry’s cause of death was due to Hypernatraemic Dehydration (severe dehydration) and a resulting acute kidney injury. His cause of death will be confirmed following the final post-mortem and the findings of an inquest which is pending with the Nottingham Coroner.

For more information and to support the family’s campaign, visit www.harrys-law.com. If you or a loved one has suffered as a result of hospital negligence, we may be able to help you claim compensation. See our Medical Negligence Guide for more information.