The Victorian Institute of Forensic Medicine has recently published a poignant article including coroner findings which is enclosed and highlights the tragic implications of a child’s death associated with communication issues between parents and the medical team.
Case Number: 2014/96 Qld Case Précis Author: Dr Rachel Marr, MBBS (Hons.) FRACGP GP and Forensic Physician
Master HM was a 9 year old boy who had been treated for infrequent episodes of asthma over a number of years. HM was not prescribed asthma preventative medication as he had minimal symptoms between exacerbations. One particular day, after developing chest tightness, shortness of breath and cough, his parents called an ambulance for HM. The ambulance officers administered salbutamol (an inhaled medication that opens airways) and transported him to the nearest major hospital where he was treated for several days with salbutamol, oxygen, prednisolone and hydrocortisone (steroids to reduce airway inflammation).
During the admission, HM’s father requested that his son be reviewed by a paediatric respiratory physician. Three days after his admission, HM’s asthma appeared to have improved and he was discharged home. He was not reviewed by a paediatric respiratory physician prior to discharge. That night, HM’s cough and shortness of breath worsened. By the early morning, HM was struggling to breathe and was ‘turning blue’. His parents called an ambulance and began CPR until the paramedic units arrived. HM was urgently transported to hospital where cardiopulmonary resuscitation continued, however, this was unsuccessful and he died.
An autopsy was performed which showed a small right-sided pneumothorax (collapse of the lung) and overlying subcutaneous emphysema (air under the skin, likely from the resuscitation attempts). There were no signs of pneumonia. The pathologist determined that the cause of death was asthma
A coronial inquest was held to look into the following issues:
- The appropriateness of discharge from hospital the day before HM’s death. The adequacy of the information given to HM’s parents about his diagnosis and management.
- The management of HM’s father’s request for a respiratory physician review during the admission. Hospital records showed that HM was seen in an emergency department a year after his diagnosis for an exacerbation of asthma.
Evidence at the inquest was provided by:
- Medical records from HM’s general practitioner (GP) and previous hospital presentations.
- The treating paediatric registrar and resident, and the paediatric specialist who took over HM’s care towards the end of his admission.
- The nursing staff involved in HM’s care during his admission.
- HM’s parents.
Two independent paediatric respiratory physicians for expert opinion. The GP’s medical records indicated that HM was first diagnosed and treated by his GP for asthma four years prior to his death. Hospital records showed that HM was seen in an emergency department a year after his diagnosis for an exacerbation of asthma. The documentation noted that HM had been diagnosed with asthma 12 months prior, though at the inquest, his parents denied giving that history. It was also documented that while in hospital, HM’s mother was given an asthma education book and observed to be administering salbutamol to her son with good technique. During that admission HM deteriorated, requiring intubation and admission to the Intensive Care Unit (ICU). The medical records indicated that his severe exacerbation of asthma was due to a viral infection and that HM’s mother was provided with an asthma action plan on discharge. In the subsequent year, HM was reviewed by a respiratory physician and treated with an asthma preventer medication. His mother attended the appointments and was given updated asthma action plans. Specialist correspondence, sent to HM’s parents, stated he had a history of a ‘severe exacerbation of asthma requiring ICU admission.’ HM’s parents gave evidence at the inquest that they were not aware HM was diagnosed as having asthma. His mother later stated she thought he had ‘seasonal’ asthma only.
The coroner heard from the independent paediatric respiratory physicians that sometimes parents are ‘in denial’ about the diagnosis of asthma in their children. This was despite medical documentation from his previous attendances that showed: HM’s parents had been told he had asthma; their receipt of multiple asthma action plans; they would administer salbutamol for symptoms of asthma; and that they had indicated a history of asthma on HM’s school excursion forms.
HM’s mother conceded that she knew she was to follow the asthma action plans, which were kept in the kitchen with his salbutamol. The coroner heard from the independent paediatric respiratory physicians that sometimes parents are ‘in denial’ about the diagnosis of asthma in their children, and that this is a risk factor for poor outcomes, including death, because treatment is not sought until the asthma is very severe. Regarding his most recent and final hospital admission with exacerbation of symptoms, the paediatric registrar and resident who initially provided care gave evidence that they had had a conversation with HM’s parents about his asthma.
They told HM’s father that the previous admission to ICU for asthma was a marker of how severe HM’s asthma could get, and was the reason they were monitoring him in hospital for a longer period of time.
HM’s father countered at the time that the ICU admission was the result of a viral infection, but this discrepancy was not discussed further. The paediatric resident and registrar stated that they had demonstrated to HM’s parents what the signs of increased work of breathing looked like, and had discussed with HM’s father the signs to look out for that would indicate worsening asthma. They had also provided the parents with an asthma action plan the morning after HM was admitted.
The paediatric specialist who reviewed HM on the morning of his discharge from hospital said she also discussed warning signs of increased asthma severity and increased work of breathing with HM’s parents, which was corroborated at the inquest by one of the nurses who said she had overhead the conversation. Both the paediatric specialist and the nurse stated HM’s parents did not object to him being discharged from hospital. During the inquest, HM’s parents gave further evidence that was at odds with the hospital documentation and evidence provided by doctors and nurses involved in HM’s care. HM’s father gave evidence that contradicted the hospital staff. He stated the doctor who reviewed HM the first morning was male (both the paediatric registrar and resident were female), that there was no conversation about signs of increased work of breathing or deterioration of asthma, and that no asthma action plan was left, though a receptionist did put some papers on the bed.
HM’s mother (who had not been present for the initial conversation) had seen the papers left by the paediatric doctors and identified them as an asthma action plan. HM’s father stated he had disagreed with the plan for discharge and wanted HM to be reviewed by a respiratory physician.
It was acknowledged by hospital staff that HM’s parents had requested a respiratory physician review HM, though this was not documented and did not occur.
During the inquest, HM’s parents gave further evidence that was at odds with the hospital documentation and evidence provided by doctors and nurses involved in HM’s care. The coroner noted that HM’s mother and father sometimes gave evidence that contradicted each other’s statements. The paediatric specialist stated that HM’s parents did not dispute the diagnosis of asthma during the consultation prior to discharge.
The specialist had not considered the possibility that HM’s parents did not know he had asthma because: they had communicated to her that HM had asthma and; HM’s mother was able to describe what was in the asthma action plan and the signs of deteriorating asthma. HM’s mother denied this but said she knew what was in the asthma action plan although she had not discussed this with the doctor. It was clear that HM’s parents did not fully understand or appreciate their son’s asthma diagnosis despite being given education materials and multiple asthma action plans.
The paediatric specialist confirmed that HM had not required any supplemental oxygen for over 24 hours before the decision that HM could go home. The independent paediatric respiratory physicians agreed that HM’s care was in line with current standard practice and guidelines.
They considered that his condition was sufficiently stable at the time of his discharge to be considered safe, providing that the parents knew the signs of deterioration and when to bring him back to hospital.
The coroner could not explain why HM’s parents gave evidence that they were not aware of HM’s diagnosis of asthma. There was sufficient evidence that they were aware of the diagnosis, had been told as much on numerous occasions, and that they knew it was not just a ‘seasonal’ illness.The coroner ultimately found that it was clinically appropriate to discharge HM from hospital that morning.
The coroner also noted that although HM’s parents were told about the warning signs of deterioration on the morning of discharge, there were missed opportunities to educate them about the nature of his condition. It was clear that HM’s parents did not fully understand or appreciate their son’s asthma diagnosis despite being given education materials and multiple asthma action plans.
A respiratory review in hospital may not have been clinically necessary but would have provided a good opportunity to further educate HM’s parents about his asthma.
HM had experienced several episodes of exacerbation of asthma prior to his final admission. His GP, paediatric respiratory physician and hospital treating teams all had opportunities to teach HM’s parents about his condition. Although it appears they did do this, as doctors we must keep in mind that ‘message given is not always message received.’
It is vital that we check that our patients and their families understand their condition, including the signs of deterioration that warrant prompt medical review. Providing medical resources without fully explaining the contents should not be considered adequate patient education.
Asking patients and their families to recall and demonstrate their understanding of the information is a vital component of patient safety in hospital and the community.
This should be followed by clear and contemporaneous documentation of the communication that takes place.
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RESOURCES Asthma Australia Education and Training. Available at: https://www. asthmaaustralia.org.au/national/ education-and-training. Royal Children’s Hospital Kid’s Health Info – Asthma. Available at: https:// www.rch.org.au/kidsinfo/fact_sheets/ Asthma/. Henderson, J et al. Asthma control in General Practice, Aus Fam Physician 2013; 42: 740-743. Available at: https://www.racgp.org.au/afp/2013/ october/asthma-control/. Larson, A. et al. Impact of structured education and self management on rural asthma outcomes. Aust Fam Physician 2010; 39: 141-144. Available at: https://www.racgp.org. au/download/documents/AFP/2010/ March/201003larson.pdf.