Suffolk’s senior coroner has written to the government following the death of a Felixstowe schoolboy who was discharged twice from A&E in the days before he died.
Regan Smith was 11 when he died on January 31 last year at King’s College Hospital in London.
He had been feeling unwell during the 10 days prior and had begun to breathe “strangely” on January 23, when he was taken to the A&E department at Ipswich Hospital. It was initially believed he had laryngitis.
On January 25 an ambulance was called, and a finger prick test showed that Regan’s blood glucose level was much higher than it should have been.
Regan was again taken to A&E in Ipswich – but the test result was not recorded, and consequently not taken into consideration by those treating him. Regan was discharged later that evening.
Regan was taken to A&E again on January 26, before being transferred to Addenbrooke's Hospital in Cambridge.
By this time, he had severe metabolic acidosis caused by previously undiagnosed diabetes. His liver then began to fail.
Regan was transferred to a specialist unit at King’s College Hospital, where he continued to deteriorate until he died.
Following an inquest held in July, Senior Coroner for Suffolk Nigel Parsley has written to the Secretary for State for Health and Social Care, Wes Streeting.
“The information to save Regan’s life (his abnormal blood glucose reading) was in the possession of the NHS at a time when lifesaving treatment could have been given to him on January 25, 2023,” Mr Parsley wrote.
“Regan’s death occurred as the result of an identifiable single point of failure (the ineffective handover process), as this led to a significant and known clinical finding being unavailable to his treating clinicians.”
Mr Parsley stated that IT systems used by the ambulance and hospital trusts were “not directly compatible”, meaning clinical information was not readily available to all personnel treating patients.
He also noted that no national protocol for ensuring basic observations were handed over by ambulance personnel and confirmed as being received by A&E staff.
Mr Parsley urged the Health Secretary to take action to prevent future deaths. Mr Streeting is required to respond by September 18.
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