Hospital shake-up after child death

12:00pm Saturday 11th October 2008

Vital changes will be made at a children's hospital after the death of a little girl highlighted major problems in training and communication.

Indya Trevelyan, 20 months old, was suffering from croup, a common childhood viral infection, but died after an emergency medical procedure went wrong at the Royal Alexandra Children's Hospital in Brighton.

On the third day of an inquest her parents Sian, 37, and Nigel, 43, from Pease Pottage, near Crawley, heard that action would be taken by Brighton and Sussex University Hospitals NHS Trust to ensure the tragedy is not repeated.

The youngster was taken to the Princess Royal Hospital, Haywards Heath, on April 14 suffering from a cough that was leaving her breathless.

She was sent home that day after her condition improved.

But the next day the breathlessness returned and she was taken to the Royal Alex.

On April 17 doctors carried out an emergency tracheotomy to find out what was blocking her airways.

The procedure appeared to have gone well but after the surgeon left the theatre the tracheotomy tube became dislodged and Indya suffered a cardiorespiratory arrest.

An investigation into the incident was carried out by the trust and will address issues of culpability and the breakdown in communication between the doctors.

Consultant anaesthetist David Campbell described how he took over from Dr Kim Daborn and said he could go home but minutes later he noticed the tracheotomy tube was standing proud and there was a risk it would pull away from the youngster's trachea altogether.

Dr Campbell tried to reinsert the tube but Indya later suffered a cardiorespiratory arrest.

He told the inquest how the usual tie that holds the tube in place was not there.

He said: "In every one of my previous experiences with tracheotomies there has been continuous paranoia about the ties.

"He described the fact the tie was missing as extraordinary."

But Dr Tony McGilligan, who was responsible for the decision not to use a tie, said it was because the ties often became soiled and the tube may have become dislodged if staff decided to change it.

Dr Campbell said although he had plenty of experience of established tracheotomies he had never managed an acute or fresh emergency paediatric tracheotomy before.

Richard Furniss, representing the family, said: "You were in the unenviable position of trying to do something you ve never done or seen done before.

"When Doctor Daborn said is it OK to leave, wasn't that the time to say something like, this is the first time I've ever managed one alone?"

A representative from the trust said: "We will address issues of making assumptions and question whether we need to think of different ways of communicating because the report does identify a breakdown in communication.

"There will also be new training in the management of paediatric tracheotomies and devices to keep the tubes in place."

The inquest resumes on Wednesday.