Letter published in The Cornishman, Thursday, November 8th, 2018
As The Cornishman reported last week, the investigation into the tragic death of 6-year-old Coco Bradford identified numerous failures in the treatment she received at Treliske.
It wasn’t recognised that she was clinically dehydrated and in clinical shock when she arrived at the emergency department, these conditions weren’t treated appropriately, and official guidelines weren’t followed while she was on Polkerris Ward. Crucially, Coco wasn’t given the rehydration treatment that she should have been. The abnormal results of tests weren’t identified and acted on, her blood pressure wasn’t obtained until 36 hours after she was admitted to hospital, and there was a delay in starting antibiotics when her clinical picture suggested she had developed sepsis.
Faulty too was the assessment of the pain that Coco was in. On many occasions she was described as ‘distressed’, ‘inconsolable’ or ‘agitated’, but her pain score was recorded as zero, not having pain, and the standard pain assessment tool was not made use of (although she was prescribed paracetamol, which would have been given as pain relief). The hospital’s Learning Disability team was not called in to help in establishing a relationship with this autistic child, who some members of staff thought was ‘unco-operative’ and ‘non-compliant’.
The purpose of the investigation was to learn lessons for the future from this sad affair. So the investigation report avoids saying who didn’t recognise Coco’s condition, who didn’t follow official guidance, who didn’t identify abnormal results, who delayed taking Coco’s blood pressure, who delayed starting antibiotics. It makes general recommendations: that’s all.
I appreciate that, as the investigation report says, when Coco was in Treliske the hospital was under great pressure. Polkerris Ward was full and it was understaffed, especially at night. In such circumstances, staff may find their patience strained, especially with patients and families who present as in some way ‘difficult’.
But individual people and their attitudes do seem to have played a crucial part in Coco’s treatment. We have a clue to this in Coco’s mum reporting that she and Coco’s elder sister (herself a clinical skills tutor in the NHS) were treated with ‘arrogance’.
Arguably, it is arrogance that leads professional people to think that they know best, that they don’t have to follow the rulebook, that they don’t have to answer questions from ordinary folk.
The investigation team were critical of staffing levels and the behaviour of some (unidentified) clinicians, but they made no recommendations for tackling arrogance among the professionals who work at Treliske.
So let me add one of my own. Anyone – patient, relative, child – is entitled to ask a question and receive a respectful, thought-about answer. Every now and again, one of these will give rise to a suggestion worth acting on. I hope the Royal Cornwall Hospitals Trust will be big enough to take this additional recommendation on board.
Peter Levin
A fuller analysis of this case will be published on this website shortly.
[Statements by Coco’s mother, Rachel Bradford, and her sister Chelsea, reported in The Cornishman (1 November 2018), can be viewed here.]