Hospital sister changed notes of boy who died after fall

Charlie Davies, who suffered from Duchenne muscular dystrophy, fell while getting undressed in his bedroom.

The 15-year-old suffered a fractured femur which, in turn, led to him developing a condition which ultimately led to his death.

John Ellery, coroner for Shropshire and Telford & Wrekin, heard that a doctor missed the fracture while a nurse altered Charlie's notes to hide that a student nurse had failed to inform her that his condition was deteriorating.

The inquest, which was held at Shirehall, Shrewsbury, yesterday heard that Charlie, of Balmer Crescent, Welshampton, fell on April 29. He was taken to the Royal Shrewsbury Hospital where he was X-rayed and was later sent home.

Dr Emily Ward told the court she had failed to spot that he had fractured his femur as had her colleague Dr Furrqh Shabbir until the following day.

Meanwhile Charlie's concerned family had already taken him to the Robert Jones and Agnes Hunt Orthopaedic Hospital in Gobowen.

By this stage he had already developed fat embolism syndrome, which led to his lungs becoming congested and heart failing. Professor Archie Malcolm said he believed Charlie's death was unavoidable.

While in hospital the court heard Charlie's pulse, heart rate and oxygen saturation levels were monitored.

These were taken by a student nurse. But despite Charlie's oxygen saturation level falling to a dangerously low 87 per cent no alarm was raised.

His saturation level then fell further to 78 per cent and action was taken to stabilise him. Sister Sheena Hughes said she had been aware that Charlie was on the ward but had not been made aware that his levels had initially fallen. It was only when his condition deteriorated further that he was transferred to the Royal Stoke Hospital where he died the following day.

Four days later Sister Hughes changed the notes to read that his oxygen level was recorded at 97 per cent rather than at 87 per cent. She said she did this because she panicked and was under a great deal of stress. Mr Ellery recorded a conclusion of accidental death.

He said: "Alteration of notes is a serious matter. The alteration occurred four days after Charlie's death. It cannot be said to have caused or contributed to his death save to highlight the importance that the reading of 87 per cent being acted upon."

Shortcomings surrounding Charlie's death have led to new procedures being implemented at the Robert Jones and Agnes Hunt Orthopaedic Hospital.

Suzanne Masden, ward manager at RJAH, said that lessons had been learned from Charlie's death and that improvements had been implemented.

For example, a new system had been introduced for patients admitted to the children's ward and student nurses are no longer to be left unsupervised until they are deemed to be competent.

An electronic system for carrying out observations had also been introduced.

Julie Roberts, acting director of nursing at The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, said: "This is a tragic case and our profound sympathies go out to Charlie's family for their loss.

"The coroner made clear that Charlie's death could not be avoided, however we acknowledge that learnings can be taken from the case. A review highlighted a number of action points and these have been implemented.

"When it became known that an error of judgement by one individual resulted in Charlie's notes being amended we commenced an internal investigation.

"We were very concerned by the conduct of this member of staff, which fell well below the standards we expect of our employees.

"A thorough investigation was carried out and we have taken internal disciplinary action and made a referral to their professional body, The Nursing & Midwifery Council."