Willow Rosie Kemp, who was just 20 months old, died at the Royal Manchester Children’s Hospital having suffered a cardiac arrest. Willow was a remarkable little girl who suffered from a number of unique natural conditions including a chromosomal defect and renal and gastric abnormalities which required careful management of fluid and electrolyte balance, particularly of her low level serum Potassium. Willow’s potassium levels had previously always fluctuated and her medical care and management was extremely complex.
On 27th June 2012 she underwent a gastrostomy amongst other procedures at the Royal Manchester Children’s Hospital. Surgically, these procedures were completed without any complications and she was transferred to the Paediatric Intensive Care Unit post surgery.
On 28th June 2012, Willow’s Potassium levels were low and her condition was such that she required an infusion of Potassium initially by way of an arterial line as well as the central line. Later that morning, it was decided that one infusion would be safer, with an infusion rate from a previous admission. The new rate of infusion was to be 12 mmols per hour, increased from 5.88 mmols per hour. The rate was almost doubled. This was a bespoke prescription regime that was outside standard policy guidelines. Dr Russell, expert Consultant Paediatrician stated that this was an extremely bold and risky decision, however one that was taken in Willow’s best interests but required careful management.
The new rate of infusion commenced however no target level was recommended. Give the risks of the increased infusion, Willow was to be monitored carefully and her blood gas levels were to be checked every 60-90 minutes. Sadly, Willow was not checked for three-and-a-half-hours at which time her blood gas reading was above the normal range. This was brought to the attention of the Specialist Registrar who advised that a repeat Potassium check should be undertaken. It was not until some time later that the Registrar brought this to the attention of the treating Consultant who immediately advised that Potassium infusion be paused and requested that an immediate blood gas be taken. He also attended and a blood gas Potassium was recorded at a level of 8.3 by which time the infusion had already been stopped. Willow’s ECG was noted to be abnormal and treatment was given to try and treat Hyperkalaemia. She was intubated but noted to have no palpable pulse. The ECG revealed Ventricular Tachycardia. CPR was commenced. A defibrillator was used and a repeat Potassium test recorded a level of 11.8. Despite further treatment, Willow was noted to be Asystole and further efforts to resuscitate her proved unsuccessful.
Dr Russell gave evidence that in his opinion, on the balance of probabilities, the failure of the Registrar to report her findings immediately to the treating Consultant fell below the accepted level of care. He was further of the opinion that the lack of planning and absence of a regime for monitoring the Potassium over time fell below the reasonable standard of care expected.
Having heard evidence from both the Pathologist and Dr Russell, the Coroner was satisfied that Willow died of Acute Bronchopneumonia and Hyperkalaemia. He delivered a narrative conclusion in which he stated that:-
“There was a failure to consider and plan how such significant dosages of Potassium should be monitored and the response to any significantly rising levels was to be managed. There was a serious failure to fully appreciate the significance and risks associated with a recorded Potassium level of 5.7 and note the increase of a period of some hours, urgently escalate a review and the seeking of Consultant advice, as well as pausing the infusion. This made a material contribution to the death.”
The NHS Trust has admitted liability for Willow’s death and her parents are due to receive a formal letter of apology following conclusion of the inquest. This is an extremely tragic case in which Willow’s death could have been avoided. Whilst clinical decisions were made in her best interests, the subsequent care and management of Willow’s requirements by those responsible for looking after her fell below the standard it ought to have done.
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For related content please see the following press articles
The Daily Mail – Baby girl died of a heart attack after being prescribed ‘exceptionally high’ amount of potassium while recovering from routine operation