A Six-year review of deaths, a district general hospital’s experience: reflection and learning.

Published Date: 30th July 2024

Publication Authors: Chilukuri. L, Abdelaziz. M

Abstract
Objectives: Neonatal and paediatric mortality has remained a challenge worldwide, despite significant improvements in antenatal, neonatal and paediatric care. Case reviews and acting on lessons learned remain a powerful training tool in paediatrics.

This is a single centre, retrospective review of all neonatal and paediatric mortality cases in order to identify common risks, modifiable factors and learning points that contribute to these cases. Examples of good practice were also identified and promoted.

Methods: All neonatal and paediatric mortality case reviews over 6.5 years from January 2017 to June 2023 were identified. In each case the patients age, cause of death and reported learning points were identified. The learning points were reviewed for each case to identify common themes.

Results: The cohort included 34 cases, including 19 neonates, 8 infants (1 month to 2 years of age) and 7 paediatric patients (2 years to 18 years of age). Therefore, 56% of the mortality cases were neonatal and 44% were paediatric. The trend in paediatric deaths was between 1–4 deaths per year, with no clear change over time. Neonatal deaths were static apart from one surge. This related to an increased incidence of extreme premature deliveries in that year.

The common modifiable factors identified in neonatal mortalities included delay in securing an effective airway (42%), hypothermia (26%) and delay in antibiotic administration (21%). The main factor implicated in paediatric mortality was the delay in recognition and acting upon shock or sepsis. Other learning points included inaccurate or incomplete documentation, difficulty in contacting the Coroner, delay in contacting Toxbase and not considering muscle relaxants in cases of ecstasy overdose.

Conclusion: This study demonstrates that the neonatal period is the most vulnerable time for a child’s survival. Technical and practical difficulties were not uncommon in neonatal deaths, including difficulty establishing a secure airway as well as establishing intravenous access to administer antibiotics in an appropriate timeframe. Clinical acumen and knowledge is needed for early diagnosis of shock and sepsis. Following policy, such as contacting Toxbase, or a Coroner, appropriately were identified learning points. The department has introduced a training program using simulation methods and introduced new equipment such as a video laryngoscope to help reduce these identified risks and modifiable factors. Effective communication with maternity for early transfer of extreme preterms to a level 3 unit remains important.

Pannell, C; Chilukuri, L; Abdelaziz, M. (2024). A Six-year review of deaths, a district general hospital’s experience: reflection and learning. Archives of Disease in Childhood. 109(A), p.400. [Online]. Available at: https://dx.doi.org/10.1136/archdischild-2024-rcpch.628 [Accessed 5 September 2024].

 

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