Call For Better Treatment For Special Needs Children After Four-Year-Old’s Death

Specialist Lawyers At Irwin Mitchell Instructed To Investigate By Parents

18.07.2015

The parents of a four-year-old boy who died just two days after being discharged from hospital have called for better treatment of children with special needs after an inquest heard evidence from representatives for the Trust and following the review of a High Level Investigation Report which highlighted  failings in his care.

Harry Procko, who suffered with autism, was first referred to A&E at Nottingham Children’s Hospital on 20th June 2014 as he was suffering from what appeared to be a stomach bug. He was suspected to be dehydrated but was discharged the next day after doctors decided he didn’t need blood tests. He died two days later on 23rd 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 Marika Procko, from Nottingham, have instructed specialist medical negligence lawyers at Irwin Mitchell to investigate the care Harry received in the days leading up to his death at The Nottingham University Hospitals NHS Trust, which commissioned a High Level Investigation report following his death. The report identified that “The opportunity to appropriately investigate Harry’s condition whilst an in-patient was missed.”

Following the inquest into his death at Nottingham Coroner’s Court, HM Assistant Coroner Connor recorded a narrative conclusion and said: “At any inquest I am required to answer four questions. My answers to those questions are that Harry Procko died at the Queens Medical Centre in Nottingham on 23rd June 2014. I return a narrative conclusion as follows.

“Harry Procko was tested for dehydration at the Queens Medical Centre in June 2014. When he first attended, he was assessed as needing a blood test and intravenous fluids. His condition remained stable and on subsequent review it was felt he was improving and no longer needed the fluids and blood test. Whilst there were areas where the care was not optimal, in terms of record keeping and delay in transferring Harry between the Children’s Emergency Department and the Children’s Assessment Unit these did not cause Harry’s death. Harry tragically deteriorated at home on 23rd June 2014 and died at Queen’s Medical Centre later that day.”

The NHS Trust’s 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. 

Expert Opinion
“This past year has been absolutely heartbreaking for the family and losing Harry so suddenly has left them with so many concerns and questions regarding their young son’s care.

“We, on behalf of the family, would like to thank the Coroner for taking the time to conduct a thorough investigation into Harry’s death and we hope that the Trust for the hospital, The Nottingham University Hospital NHS Trust, will learn lessons from the issues identified in Harry’s case and provide assurances not only to Richard and Marika, but also other families, that training and guidance has been put in place for staff at the Hospital when caring for children who have special needs.

“We will continue to work with the family and the representative of the NHS Trust to ensure that the recommendations from the High Level Investigation Report and the Coroner are put in place, to prevent future deaths.”
Adam Wright, Solicitor

Harry was taken to his GP in June this year with a suspected stomach bug with symptoms such as diarrhoea, vomiting and weight loss. 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 his GP.

The hospital assessed Harry as a category 2 patient, which meant 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 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, and 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 as he was becoming increasingly agitated. Harry was allowed home on the provision that he would  return the following morning.

Harry and his parents returned to the hospital the following day. The  doctor said that Harry seemed better and he was discharged, saying that a blood tests and other investigations were no longer necessary. His condition remained the same throughout the next day but on 23rd June Harry collapsed and turned blue. He was rushed to hospital by ambulance but resuscitation attempts were unsuccessful and Harry died.

A blood test carried out during Harry’s attempted resuscitation 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 NHS Trust’s High Level Investigation Report highlighted two main failures in Harry’s care:

  • 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 set out a number of recommendations and an apology was issued by the Chief Executive to the family.

Commenting after the hearing, Richard, 49, said: “Since Harry died, my family and I have really struggled to come to terms with what happened to him. We were left with so many unanswered questions as to why the tests were not carried out sooner.

“Harry was born with a hole in his heart which had been successfully treated so we know from his early years the importance of getting the right medical treatment as soon as possible. This is why we didn’t hesitate in taking him to the doctor.

“We are grateful to the Coroner for conducting a sensitive investigation over the past few days as it has helped us obtain  more information about what caused his death, and we now hope that with the help of our legal team at Irwin Mitchell, we can continue to raise awareness about the importance of better standards of care for families with children with special needs. I hope that the Trust has learned lessons from my Son’s death so no one else has to go through losing their child.”

The family have set up a campaign after Harry died calling for Hospital guidelines to be changed when dealing with children with special needs, please visit this website for more information www.harrys-law.com