A seven-year-old Ipswich boy died after equipment monitoring his breathing was turned off for almost three hours at a private London hospital, an inquest heard today.
James Dwerryhouse, who attended Thomas Wolsey School, suffered a catastrophic brain injury at the Portland Hospital when the equipment used to monitor his sleep was shut down without a doctor’s permission.
He died at East Anglia’s Children’s Hospices Treehouse Hospice in Ipswich when life support was withdrawn the following day.James suffered from sleep apnoea – interruptions to breathing while sleeping that can be life threatening – and was found unresponsive by night staff at around 4am on August 26 last year.
The youngster, who had Down’s Syndrome, was an inpatient for a routine bowel operation to treat a condition that meant he still had to wear a nappy.
He also had several other conditions including mild hearing loss, poor eyesight, epilepsy and sleep apnoea.
His father John said that after coming round from surgery on August 25, his son had been energetic and playing with his toys.
Around 4.20am Mr Dwerryhouse, who has five children, received a call telling them that James wasn’t well and that they needed to attend the hospital immediately.
When they arrived, their little boy’s eyes were half closed, he was covered in a rash and his dilated pupils indicated he was brain dead.
Mr Dwerryhouse said: “The consultant gave me a look to say ‘’The hospital messed up.’”
He said: “If James was fighting with them and taking his monitors off I wouldn’t have had a problem with that, because James was very much a “take one off, take them all off” kid.’
“I have no recollection of a conversation saying ‘Could the monitors be taken off until he settles?’
“I can’t remember but I’m not saying there wasn’t a conversation about monitors but I wouldn’t have asked them to be taken off.”
Westminster Coroner’s Court heard the parents had asked that James not be given a CPAC monitor – which involves a full face mask – and instead that a blood saturation monitor be used.
The monitor is just a little peg put on the finger or toe and is what was used at home, although the alarm very rarely went off. Dr Sanjeev Sharma, one of the two doctors who treated James in Portland Hospital, said monitors would rarely be removed on the decision of nurses. It was a decision that had to be escalated to a doctor.
He had agreed with James’ parents that the use of a CPAP machine was unnecessary, he said.
Dr Konstantinos Dimitriades, the resident medical officer on duty that night, said that even if a child was fractious they would still have to wear their monitors.
He told the court James had been bright and happy before falling asleep and had wanted to shake his hand.
Dr Dimitriades was the first doctor to arrive at James’ bedside when he went into cardiac arrest and noticed there was no data from any monitors for the previous three hours.
“His parents asked me if he had his monitors and I said I didn’t know,” he said.
When he was asked if he would have permitted the monitors to be taken off, he replied: ‘No, the central stand of intensive care is monitoring.
“You can settle down a child, you can always get it done. You can put the monitor on a toe covered by a sock, you can use diversion – as soon as the child’s attention is diverted somewhere else the monitor goes back on.”
The inquest heard nurses at the Portland were given a 30-minute break before midnight if they were on a 12-hour night shift, and between a one-and-a-half to two-hour break in the early hours of the morning.
James’ nurse Mr Cachero went on his break shortly after 2am while Mr Dwerryhouse was lying in the bed with James on his chest just trying to get him to settle.
He said James had been pulling off his monitors and lines, and thought it was okay for him to have them off while his father was with him and the boy was awake.
The nurse claimed that he and Mr Dwerryhouse had agreed that the monitors didn’t have to be on while he was with him.
Mr Cachero said he told the nurse that was covering for him, Anuradhapura Bhupathiraju, that James needed his monitors back on once he was settled.
When he returned at 3.58am, Mr Dwerryhouse had left and James was asleep but had still not had his monitors reconnected.
He said that he first thought there was an issue with the blood saturation monitor when he connected it because it was reading zero, and even fitted a new one, before he realised James wasn’t reacting to him.
He became concerned when the youngster didn’t wake as he adjusted his position to fit his lines.
Despite his concerns the crash team isn’t recorded on CCTV running to James’ bedside until 4.18am. James was unconscious by that time.
“I was trying to move slowly, I didn’t want to disturb him, but when I moved his head and all these things that’s when I realised that he wasn’t moving,” said Mr Cachero.
He said that Ms Bhupathiraju had told him that Mr Dwerryhouse had only left a matter of minutes before he returned from his break, when in fact he had left just before 3am.
Ms Bhupathiraju, a nurse of 33 years experience, was warned that she didn’t have to answer any questions that she felt might incriminate her.
She said that James was sleeping and comfortable, and that she was aware of his sleep apnoea because earlier in the shift she had asked to have his morphine dose reduced over fears that it might exacerbate it.
Ms Bhupathiraju said that James’ parents hadn’t wanted his monitors on, but admitted when pressed that her clinical knowledge of his best interests was more important than the wishes of the parents.
She also admitted that 99.9% of patients on an intensive care unit would be rigged up to various monitors at all times.
A police investigation was launched when James doctors at home in Ipswich raised their concerns with the Met.
DS Adrian De-Villiers told the court that the hospital’s errors didn’t meet the threshold for corporate manslaughter, but added: “That doesn’t mean there weren’t individual failings on the day.”
Portland’s chief nursing officer Elaine Stewart, who led the internal investigation, said that staff were not permitted two to three hour breaks while on shift, as both Mr Cachero and Ms Bhupathiraju had claimed.
Instead the maximum they could take was one hour and 15 minutes.
Mrs Dwerryhouse challenged Ms Stewart over the fact she hadn’t been allowed to stay with James when she had stayed on every other overnight hospital visit.
She and her husband were instead told they could pay £300 for a room elsewhere in the hospital or or they could get a hotel.
“This was a child that was not just physically ill, he had special needs, he was signing - we offered the hospital his ‘passport to communication’ but it wasn’t taken up,” she said.
“You couldn’t talk to him. You couldn’t sign to him.”
Ms Stewart said the Portland had now reviewed its policy on special needs children and that she had been unaware of their situation at the time James’ operation was booked.
Adjourning proceedings to consider her conclusion, coroner Dr Shirley Radcliffe said she had “concerns” about the hospital and specifically about Ms Bhupathiraju.
She said: “I have concerns about Nurse Bhupathiraju and her competency to practice and I’m going to make a referral to the Nursing and Midwifery Council.
“I would be concerned if she had any further clinical duties at the Portland Hospital.
“I have to consider whether I should make a referral to the Crown Prosecution Service for gross negligence manslaughter.
“I don’t think it reaches the threshold for that. I think it was general incompetence and I think the NMC is the correct route.”
Recording a verdict of hypoxia ischemic brain injury as a result of sleep apnoea, Dr Radcliffe said: “I believe that Nurse Cachero made it clear to Nurse Bhupathiraju that the monitoring should be reapplied when James fell asleep but he accepts that he should have kept the monitoring on and the decision to remove it should have been escaped to a doctor.
“However I consider him a capable and conscientious nurse who genuinely thought it was safe while he was being watched.
“I am concerned about Nurse Bhupathiraju. I am not sure how much she knew about sleep apnoea.”
Speaking outside of court, James parents described their son as a ‘Ray of Sunshine’ who lived every day to the full.
Mrs Dwerryhouse said the inquest was a ‘step on the road’ to getting over his death.
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