Hospitals

UK baby’s death shows dark side of health IT, poor processes

England's top health official on Tuesday publicly apologized on behalf of the National Health Service in the December 2014 death of 1-year-old William Mead.

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Monday’s story about misdiagnosis in the death of a cousin of former President Bill Clinton was nothing compared to the tragedy of an infant who died in the UK, also from misdiagnosed sepsis. The British case is becoming a sad lesson in how poorly implemented health IT and siloed health information can be deadly.

England’s top health official on Tuesday publicly apologized on behalf of the National Health Service in the December 2014 death of 1-year-old William Mead.

“I have met William’s mother, Melissa, who has spoken incredibly movingly about the loss of her son,” Health Secretary Jeremy Hunt told members of the British Parliament, according to the Daily Mail. “Quite simply we let her, her family and William down in the worst possible way through serious failings in the NHS care offered, and I would like to apologise to them on behalf of the government and the NHS for what happened.”

As the official NHS account goes, Melissa Mead called NHS 111, a free, nonemergency help line for all of England, the day before William’s death. The person who answered, like all front-line 111 call handlers, did not have medical training, but instead must rely on a set series of questions to triage each case.

Hunt said that these personnel “are trained not to deviate from their script,” according to the Daily Mail. However, an NHS report on William’s death, released last summer, recommended that call handlers be trained to “appreciate when there is a need to probe further, how to recognize a complex call and when to call in clinical advice earlier,” Hunt said.

“It also highlights limited sensitivity in the algorithms used by call handlers in the signs relating to sepsis.”

In other words, the clinical decision support system wasn’t built properly.

Worse, Melissa Mead had taken her son to several physicians and had spoken to medics with better training than the 111 front-line representatives at least in times in the child’s last 11 weeks of life, the newspaper reported. None noticed that William’s health had been deteriorating.

The day Mead called 111, she also spoke to an after-hours general practitioner who did not have access to the boy’s medical records, according to the Daily Mail. Even so, William’s regular GP “had not recorded all of the relevant information in his notes,” BBC News reported.

William’s cause of death initially was recorded as “natural causes,” according to the BBC, but an autopsy later revealed that he had had septicemia, the result of a lingering chest infection. That form of sepsis was treatable.

Photo: Flickr user FastJack

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