A report into the hospital treatment given to a child who died two days after her first birthday has revealed 'delays' in elements of her care - and made recommendations to ensure signs of septic shock are spotted earlier.
'Bubbly' Maddison Rose Patricia Halliday was rushed by ambulance to North Manchester General hospital on October 20 last year after becoming feverish at home. She died the following day after being transferred to the Royal Manchester Children's Hospital.
An inquest into her death has not been held. But a clinical case review of the hospital treatment she received has revealed that she contracted sepsis after suffering an ear infection - and that communication issues, 'compounded' by logistical problems - occurred during her treatment.
Septic shock is a severe complication of sepsis in which blood pressure drops to dangerously low levels.
Her parents, Josh Holliday and Shannon Rhodes, from Bury, spoke last year to the Manchester Evening News of their heartache, days after they sat at her bedside as she passed away. They described the tot as 'amazing' and the 'happiest child' they had ever met.
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Maddison's tragic last hours
Maddison was taken to the Paediatric Emergency Department (PED) at North Manchester General Hospital on the morning of October 20 2022.
She presented as 'generally unwell' on arrival, with a rash on her back and legs. Her family said she had been 'floppy, irritable, and vomiting'.
Until then, she had been 'healthy and developing well', apart from an ear infection, for which she had been taking antibiotics. In her first review, a junior doctor was concerned she there were signs of sepsis from the ear infection.
She was then reviewed by the paediatric team, where it was noticed that her ear infection was 'not improving' with antibiotics and doctors concluded she needed to start antibiotics through an intravenous line. Plans were put in place for her to be admitted to the Children's Ward at the hospital.
Her parents noticed the rash that she had developed had changed, with staff confirming she had developed a spreading, non-blanching rash. Her dose of antibiotics was increased to levels used to treat meningococcal sepsis.
Despite this, Maddison’s blood pressure fell, and the report outlines how she 'deteriorated rapidly'. At 11am, a 'crash call' was put out - an emergency call that went to paediatric and anaesthetic teams.
Paediatric, Anaesthetic and Emergency Department consultants, as well as other members of their medical and nursing teams, attended her bedside 'urgently'.
Intraosseous (IO) ie into the bone - needles were inserted into Maddison’s legs to provide fluids and medications quickly. Blood test results later suggested she had only been unwell for a short time.
The decision was made that she needed to go to a a paediatric intensive care unit. The North West Paediatric Transport Service (NWPTS) agreed to transfer Maddison to the Paediatric Critical Care Unit at the Royal Manchester Children’s Hospital.
While still at North Manchester General, Maddison was given anaesthetic medicines, intubated and placed on a ventilator. She was also given continuous sedation and pain medicine so that she remained calm.
After NWTS arrived at the scene at around 1.30pm that day, Maddison was stabilised with treatments. As well as additional blood tests, she was given further medicines to treat low blood pressure and suspected sepsis.
But tests revealed her blood was not clotting normally and she was at risk of excessive bleeding - a complication caused by her sepsis.
By 5pm, the report outlines, Maddison's blood pressure and heart rate had dropped and she went into cardiac arrest. She was given four minutes of chest compressions and adrenaline before her heart rate and blood pressure improved.
Once she was stable enough to be transferred she was taken to the Royal Manchester Children's Hospital, but had another cardiac arrest on arrival that lasted for six minutes.
Maddison remained on a ventilator and received multiple drugs and infusions to keep her blood pressure up and improve her heart function. She also continued with antibiotic treatment and was put on a machine called a haemofilter to take over the function of her kidneys, which had stopped making urine.
Blood results revealed she had developed multi-organ failure due to her sepsis affecting her kidneys, liver, blood and heart.
Her infection, described as being 'overwhelming' meant she continued to deteriorate. She died at 1.40pm the following day with her parents and grandparents at her bedside.
Key findings and areas of concern raised in the report
After being admitted to hospital, the report outlines, Maddison 'quickly developed signs of sepsis' and continued to deteriorate even after her underlying infection was treated with IV antibiotics.
She also did not respond to increasing amounts of medical support, and 'eventually succumbed' to the complications of septic shock and multi-organ failure.
The report concluded that when Maddison began to deteriorate, concerns 'were not immediately escalated' to the Emergency Department (ED) consultant. There was also a delay in the paediatric team answering the bleep that was not escalated up to the ED or Paediatric consultant as per protocol.
The Emergency Department at North Manchester General on the night in question was also reported as 'experiencing a higher than usual volume of patients' with doctors looking after other acutely unwell children, stretching resources.
The report added there had been 'a missed opportunity' for the paediatric team to remain with Maddison in the Paediatric Emergency Department after their 'first review'. However, the team were also dealing with other sick children on the children’s ward and the team felt that Maddison was stable and so left the department.
However, after the 'second review', 'it should have been identified' that Maddison was showing signs of sepsis with low blood pressure, but the paediatric team left the department to return to their work on the paediatric ward as they felt she was stable.
A delay in the insertion of IO needles into Maddison’s bones to allow additional administration of fluid and medications was also reported. The teams treating Maddison reportedly became 'over-focused' on insertion of an intravenous cannula, with two IO needles inserted into Maddison’s tibias stopping working.
The report stated that although this is a common situation in paediatric patients, the insertion of further IO needles was delayed as the team attempted to insert a cannula - and this may have been due to inexperience of the team members in inserting the needles into locations on the body other than the tibia in children.
The report concluded that although she seemed 'brighter' after her initial treatment at North Manchester General, Maddison's low blood pressure and rising blood lactate were 'not immediately recognised as in indicators she was developing septic shock' as she appeared stable.
She 'rapidly deteriorated' and, although her treatment was escalated, developed 'fulminant septic shock with multi-organ failure'.
The report concluded that the 'several delays' in Maddison's care at North Manchester General - primarily focused on communication between the paediatric and emergency department teams - along with 'missed opportunities' to request a consultant review from the ED or paediatric team, had been 'compounded' by logistical difficulties related to the technology, equipment availability and competing demands on staff, with multiple unwell children in different locations within the hospital.
The report made 13 recommendations to the hospital following Maddison's death, with a number of actions already taken by the trust in response. They included that lessons learned from Maddison’s death should be shared with 'all staff involved and the wider teams to ensure future similar patients are recognised earlier and managed differently'.
Recommendations made include:
- Sepsis screening tool and sepsis recognition refresher training for emergency department staff.
- A senior doctor in the emergency department at North Manchester General needs to maintain oversight of critically unwell children, to ensure early recognition of sick or injured children that require senior clinical review. The sick child escalation pathway needs to be followed if there is any delay in paediatric specialty review.
- Refresher training for paediatric emergency department (PED) and paediatric staff on intraosseous needle insertion in children.
- Simulation training to be undertaken by PED and paediatric teams in the management of sepsis, septic shock and the deteriorating child.
- The learning from Maddison’s death to be shared with all staff involved and the wider teams to ensure lessons learnt, and future similar patients are recognised earlier and managed differently.
- A review of all time-critical equipment within the PED to ensure adequate stock.
- Wi-Fi and pager system to be reviewed.
- Doctor and nursing induction to include details on when and how to activate the MHP (Major haemorrhage protocol). Staff refreshers will be provided as part of study days and weekly Departmental Simulation.
- The porters will be given additional training around the process for responding to a MHP call, and their role in collecting and delivering time critical blood products. Refresher days have also been organised for the team.
After the M.E.N contacted the Manchester University NHS Foundation Trust, Matt Makin MA MD FRCPE, Medical Director, The North Manchester General Hospital, said: “We wish to again offer our deepest sympathies and condolences to Maddison’s family. We recognise that this is an extremely difficult time for the family and we are co-operating fully with the inquest.”
