Archie Donald died following a heart attack in November 2019 two weeks after blood tests showed indications of a potential infection.
The death of a three-year-old boy at a Glasgow hospital could have been avoided if an abnormal blood rest result had been acted on sooner, a sheriff has ruled.
Archie Donald died on November 20, 2019 at the Royal Hospital for Children (RHC) in Glasgow after suffering from an infection.
Born on July 22, 2016, Archie suffered from congenital nephritic syndrome (CNS), a chronic kidney condition that required ongoing medical treatment – and, in 2017, the removal of his left kidney.
During a routine outpatient appointment on November 5, 2019, a blood test found Archie’s C-reactive protein (CRP) level was 98mg/l (milligrams per litre) – well above the “normal range” of 0-10mg/l.
CRP, which measures inflammation levels in the body, is an indicator of infection.
Despite the elevated level, Archie was not assessed for infection and his blood cultures were not taken, and he was allowed to return home.
During his next outpatient appointment on the morning of November 19 medical staff noticed he was “very pale” and that he had developed a heart murmur.
Blood tests were done and he was admitted for a blood transfusion to address low haemoglobin levels, and for investigations into his heart murmur.
After being admitted to a ward that evening Archie was checked regularly and given further tests, and nurses administered antibiotics.
However in the early hours of November 20 his condition was found to have deteriorated, and at 3.36am his mother Caitlin Donald pressed the emergency buzzer as Archie had stopped breathing.
Efforts were made to save his life, but he was pronounced dead at 4.36am having suffered a heart attack.
Samples from his intravenous line earlier that evening later tested positive for a bacteria called Enterococcus faecalis.
A fatal accident inquiry (FAI) into Archie’s death was held before Sheriff Thomas Millar at Glasgow Sheriff Court.
In his determination, the sheriff said Archie’s death could “realistically” have been avoided if his elevated CRP level on November 5 had been acted upon.
He said had blood cultures been ordered, they would “on balance” have tested positive for Enterococcus faecalis, and “prompted further investigations particularly for appropriate antibiotic treatment to treat or slow progression of the infection”.
The sheriff also noted a failure to follow the “appropriate guidelines and anticipatory care plan in place for Archie”, which he said meant an infection specialist should have been consulted and/or blood cultures ordered where there was a “possibility of infection”.
He said Archie was regularly found to have elevated CRP levels between October 8 and November 5.
Sheriff Millar also noted Archie’s raised CRP level on November 5 was not noted on his discharge letter, and that it would have been raised at a subsequent post-clinic multi-disciplinary team meeting, but that this meeting got rescheduled.
The 39-page judgment added that while the source of the infection is unknown, “for the avoidance of doubt, the source was not connected to Archie’s attendances at the RHC”.
Sheriff Millar ended his determination with an expression of sympathy for Archie’s family.
“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,” the determination read.
“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.
“The death of any child is a tragedy, but Archie’s even more so.”
Following publication of the determination, Procurator Fiscal Andy Shanks for the Crown Office and Procurator Fiscal Service, said: “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.
“Archie’s family have been provided with a copy of the sheriff’s determination and our thoughts are with them at this time.”
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