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Fabio Alves-Nunes

Volume 498: debated on Tuesday 27 October 2009

Motion made, and Question proposed, That this House do now adjourn.—(Mr. Watts.)

I am very grateful to have the opportunity tonight to raise the case of my constituent Fabio Alves-Nunes who died, avoidably, aged five. By unhappy coincidence, I also attended earlier today the funeral of my constituent, Lance Corporal James Hill of the Coldstream Guards, who was killed in Afghanistan aged 23. It is sad to reflect that the bereaved families live only about 100 yards apart.

The death of a young person is especially harrowing, and never more so than when it is avoidable. Everyone associated with it will plague themselves with the question, “What if I had acted differently?” It will be the parents who feel the loss most keenly and who will pose that question most self-critically.

Corporal Hill’s parents know that their adult son chose to go into the Army, and without such decisions by young men and women our nation would be defenceless. Equally, Fabio’s parents, Ricardo and Anna, know rationally that they are in no way responsible for his death. I hope that this debate will be another opportunity to reinforce that emotionally.

The key events in this sad story are as follows. On 7 February 2008, Fabio presented with the symptoms of chickenpox. The following day, Anna asked her GP practice whether he should be seen by a doctor. The surgery receptionist said no. His parents could not have been expected to know about the dangerous link between eczema and chickenpox, but a check of his record at this stage would have revealed that.

Fabio’s condition deteriorated at home. He was not eating and hardly drinking; his bedding was soaked in a pinkish fluid; his clothes were being changed three or four times a day. On 13 February his parents requested a home visit by the GP. This was declined. The receptionist told them not to be alarmed, that chickenpox can look worse than it is, and to put him in cold water and administer Calpol. The next day they spoke again to a GP, who advised them to call the out-of-hours service as the practice was about to close. When they did this, they were told that the wait could be lengthy.

At this point Anna and her brother drove Fabio to East Surrey hospital. He was quickly discharged home in circumstances to which I will return, then cared for at home for another two days before his parents called an ambulance on the morning of Sunday 17 February. It took 24 hours for the hospital to realise the critical nature of his condition and transfer him to the paediatric intensive care unit at St. Evelina’s in London. Doctors there were unable to save him ,and Fabio died on 1 March 2008.

To the hospital’s credit, staff quickly realised that they had a disaster on their hands and set up a review. A serious untoward incident was declared by the trust on 20 February 2008 following concerns raised by the team who took over Fabio’s case on the Monday morning. This led to an internal and an external investigation of Fabio’s care.

The external investigation was led by Christine Gyles, Assistant Director of Governance at Darent Valley hospital, assisted by two consultant paediatricians and their senior nurse for children’s services. It is an excellent and detailed piece of work, unsparing of the trust in its conclusions. It ran from May to July 2008. The report is available to the Minister and was the subject of wide media comment when it was released to the family nearly a year after it was received by the trust.

It is clear from the report that Fabio should not have been discharged when he first presented to the hospital. Doctors failed to identify the danger of the connection between chickenpox and eczema, and in one of the few points in the report that I would question, it states:

“Dr. (name redacted) was not aware of the association between eczema and chicken pox when he saw Fabio. This is understandable for his level of experience."

I am alarmed that a senior house officer in paediatrics would not have been aware of the link. It is not clear when the next examination of Fabio by the paediatric registrar took place or whether he or she was made aware of Fabio’s eczema. It was this examination, unrecorded in the medical notes, that led to the decision to discharge and also not to treat Fabio with Acyclovir. This is perhaps the moment when Fabio was least well served.

The report also considers the care given to Fabio when he was brought back to East Surrey hospital by ambulance on the morning of Sunday 17 February. For this period the report identifies 39 areas of clinical concern and 15 serious points for the doctors on duty. It also records two areas of notable practice. Overall the report is excoriating about the record maintenance and the failure of nurses and junior doctors to challenge inappropriate conclusions by more senior medical staff.

The overall conclusions of the review panel bear repeating:

“Fabio was presented to ESH”—

that is, East Surrey hospital—

“on 14th February 2008. He should have been admitted and treated aggressively for his chicken pox at that point.

Fabio re-presented to ESH on 17th February 2008. Overall there was a lack of recognition on the part of the nursing and medical staff how sick Fabio was. The focus of attention was on Fabio’s skin, rather than the whole picture, until the morning of 18th February.”

I was struck by the comment on page 24 of the report that

“it was clear that even three months after the event, staff were clearly still traumatized, remembering every detail of the event and questioning their own abilities”.

Although I am now satisfied that weaknesses in the initial internal report have been identified, they may have effected the subsequent coroner’s report. The trust commissioned the external report and I am satisfied that it has taken it seriously and is implementing a comprehensive plan to address areas of concern.

However, there are wider issues that are the responsibility of the Minister and her Department. First, on page 5 of the external report, the Darent Valley team lays down a clear recommendation for the Government:

“It is clear that a recent alert (July 2007) regarding the virulence of the chickenpox virus from the regional PICU”—

that is, paediatric intensive care unit—

“and the Health Protection Agency (HPA) were not disseminated. If they were it would have provided an added safety net and alerted GPs, A&E and Paediatric staff to the risks of deaths associated with extensive chickenpox.”

Secondly, I draw to the Minister’s attention the recommendation that there should be a process for investigating the primary care alongside the hospital care. It was not the hospital alone that failed Fabio, but I have not seen an equivalent forensic dissection of decisions made at primary care level. The failure of the GP practice to be alert to the potential complications arising from chickenpox from conditions such as eczema is an oversight that would strike most people as unacceptable.

Thirdly, if there is one simple lesson to be drawn from Fabio’s death it is that all children whose chickenpox prompts their parents to seek medical advice should be checked for eczema. I would be grateful for the Minister’s reassurance that that will be re-communicated through the NHS, including to NHS Direct operators’ drop-down screens.

It may be in that respect that Fabio’s tragic story has already saved a life. The first substantive paragraph of the external report states:

“We believe that credit should be given to the Trust in taking the decision to invite an external opinion in order to learn from the very sad death of a 5 year old child. As such we would like to thank you for the opportunity this review has given to our paediatric team to examine practice and learn lessons which we can take back to our own services.”

In September this year, after a follow-up article in the Daily Mail, this message was posted on Mail Online by a Julie Knox of Gravesend:

“My heart broke reading this story especially as it so easily could have been my daughter if it wasn’t for the fantastic care she received at Darent Valley Hospital. About 3 weeks after recovering from chickenpox, my 4 year old daughters eczema became inflamed with more chickenpox like blisters. She was referred to the childrens ward by my doctor and they admitted her for 4 days where she received”


“antibiotics and anti-viral drugs. A week or so after coming home, she had another flare up but because my doctor was aware of what had gone on, she was put on a further course of antibiotics to clear it up. She was diagnosed with a super infection of the eczema (viral and bacterial). Her body had gone into toxic shock and we will be forever thankful that the hospital acted so quickly…My deepest sympathies go to Fabio’s family.”

Of course, it was Darent Valley’s paediatric team which conducted the inquiry more than a year earlier.

One of the least satisfactory parts of the story is that of the coroner. Ricardo Nunes was denied the chance to give evidence, but Anna was called, despite the fact that they were with Fabio at different times. I am particularly concerned that the coroner reached his verdict 12 days ahead of the presentation of the external report to the trust. It is clear that the coroner would not have had the time or expertise to achieve the same level of detail or reach the same conclusions as the external team. He should have been able to draw from that report’s findings.

It has been put to me that the coroner had access to the same information as the external inquiry. However, to suggest that the coroner would not have been assisted by the product of three months’ work by experts is plainly ludicrous. I am sure that the Minister will not want to advance that argument. I would be grateful if she communicated my concerns to the Ministry of Justice and sought a review of the handling of Fabio’s case, and invite her colleague to answer the points that I have raised this evening.

The parents were advised that it would be unwise to challenge the coroner’s conclusion of death by natural causes because it would alter nothing. That may be true, but I do not regard the verdict or the process as satisfactory. Fabio’s parents were represented pro bono and appealing to the High Court for a judicial review was simply not a practical option.

The cause of Fabio’s death was the lack of care and the lack of appropriate intervention to treat his naturally developing fatal condition—the serious eczema combined with a virulent strain of chickenpox. I understand that a narrative verdict or a verdict of misadventure may have been possible. Given that the coroner did not see the external report, I find it distasteful that the trust stands by his verdict, despite acknowledging the

“missed opportunity in intervening earlier in Fabio’s case”.

Any suggestion that Fabio was going to die anyway is simply wrong. The papers prepared for the trust’s Healthcare Governance Committee in July this year, particularly the overview, make offensive reading, emphasising the coroner’s verdict and the parents’ decision to take the medical advice offered when they took Fabio home.

Finally, I wish to raise the issue of how hospitals help bereaved parents. It seems clear that the key elements of the trusts “Being Open” policy were not followed. On page 3, the policy states:

“Communication should be timely.”

Copying the parents into the external report more than 10 months after it was received was, I am afraid, disgraceful. It also says:

“Patients and their carers should also be provided with support in a manner appropriate to their needs, such as a translator or independent patient advocate.”

One of the reasons given for the “Being Open” policy is to prevent formal complaints and litigation claims. I fear that this principle underpinned the approach to the Nunes family, rather than the compelling reasons of improving understanding of the dangers exposed by this case and helping the family to cope better with the effects of Fabio’s loss.

The family has been paid the full amount they requested in compensation, having resisted the temptation, in the words of some commentators, “to sue the socks off the hospital”. However, it is quite wrong that a process for helping bereaved parents should be geared to avoiding litigation—that should not be its purpose. When I tried to work out the sort of support that patients should receive, I discovered that it existed in the form of the trust’s patient advice and liaison service. I understand this to be a patient’s friend or an honest broker set up to be at one remove from the interests of the hospital trust. However, this service falls away once the issue becomes a complaint or the subject of likely legal action. So, the worse the problem, the less likely it is that that excellent approach will be used. Understandably, Ricardo’s first contact with the hospital after his son’s death made it clear there would be a complaint, so he was dealt with by the complaints department, which understandably has a different outlook from that of PALS.

In such cases as Fabio’s, legal action and formal complaints are highly likely, if not inevitable. Bereaved parents should not have to grope towards getting the appropriate advice through whatever means are available to them. When they are reduced to having to use the media as a lever, then we have all failed. Does the Minister agree with me that PALS should be there for the patient, at one remove from the interests of the trust in defending its reputation and that of its employees, throughout the process?

Unsurprisingly, a case as tragic as Fabio’s has led many to reflect on what might have been. An anonymous nurse posted this in response to Fabio’s story:

“As a nurse, stories like this make me ashamed to work for the NHS. All too often us ward nurses have concerns about sending patients home, only to be over ruled by medical staff and nursing management who only see a snapshot of the patient, you don’t need to work in the healthcare profession to see that this case of chicken pox is far from routine. As a parent I have also been given bad advice from GPs and have had a patient almost die of septicaemia after being told by a GP receptionist to take paracetamol and drink plenty of fluids. My advice, never take advice from a receptionist and stand your ground. I hate to say it, but those that shout loudest usually get the treatment.

Just try to remember some of us nurses and doctors really do work hard and care an awful lot.”

I hope and believe that this nurse is too hard on her profession, but there are in this case a number of junior doctors, senior house officers, registrars, consultants, nurses and matrons, along with GPs and receptionists, who share that desire to put the clock back.

There are only losers in the story of how Fabio died. But the Minister can help to ensure that there may be winners from the lessons learned. I think that there already may be one—the little girl from the Knox family in Gravesend. I hope there will be other children who might now benefit from better practice and a better understanding of the risks of chicken pox. And I hope that we will never again see the distressing pictures of Fabio repeated in the case of another child.

I congratulate the hon. Member for Reigate (Mr. Blunt) on securing this debate on a very sad and distressing series of events. I have listened closely to the points that he made both now and in advance of the debate. As we know, the death of a young son or daughter is, under any circumstances, an unbearable loss, so my first thoughts this evening are with the parents of Fabio, and I thank the hon. Gentleman for giving me the opportunity to express my personal sympathies direct to the family before the debate.

I also wish to express my sympathy to the family of Lance Corporal Hill, whose tragic death was mentioned early in the hon. Gentleman’s speech. I am sure that the whole House would wish to join me in expressing our condolences to both families.

I completely understand the need to understand the circumstances of the death of Fabio and to gain some reassurance that lessons have been learnt and that such a tragedy will not happen again. I agree with the hon. Gentleman that the care that Fabio received at various points in his illness was simply not good enough. However, it is important that we note the coroner’s verdict. The coroner recorded a verdict of natural causes and concluded that there was no evidence that the outcome for Fabio would have been different had he been admitted to hospital sooner. However, the trust accepts that there were shortfalls in the care provided by East Surrey hospital, with staff failing to recognise the severity of Fabio’s condition in order to act accordingly.

I know that it does little to ease the pain of losing their child, but I want Fabio’s parents to know that the trust is taking measures to stop this happening again, and I would like to outline those to the House. The trust’s action plan responds to the external review’s recommendations, and includes new guidelines for staff on admissions. Those guidelines will ensure that doctors follow a standard approach, including the need to consider whether a child has eczema.

I am also informed that the trust has increased staffing levels in paediatric accident and emergency, it has improved and continues to improve staff training, and it has developed better communication and triaging procedures in the child assessment unit, all of which were flagged in the external review as potential weaknesses. In addition, the trust has strengthened its internal processes for disseminating Health Protection Agency alerts internally, which the report also said failed to happen at the time of Fabio’s admission.

I also want to say a word about Fabio’s treatment at primary care level, to which the hon. Gentleman rightly alerted the House. He is right to say that this has not yet been fully explored, and until recently the family had not made a complaint about that. However, the Surrey primary care trust is now investigating as a matter of urgency the reports that the family contacted their GP surgery several times before taking Fabio to hospital. I also understand that Surrey PCT is working with the Health Protection Agency to improve the way that cases of infectious diseases are dealt with. That includes better information-sharing between GPs and primary care staff.

The hon. Gentleman also spoke about wider lessons, particularly around drawing attention to the possible complications for children with eczema. The current clinical guideline from NICE on atopic eczema in children from 2007 makes it clear that any secondary infection should be promptly identified and treated. In the vast majority of cases, such as the story of the little girl whom the hon. Gentleman mentioned, that is exactly what happens. Health professionals understand the risks and respond accordingly.

As the hon. Gentleman is aware, NICE routinely reviews its guidance every two to three years to ensure that it reflects significant changes in the evidence or clinical practice. That would be the natural moment for clinical experts to reflect on whether it is necessary for stronger signposting of eczema as a complicating factor in chickenpox. The guidance on atopic eczema in children is expected to be reviewed next year.

Deeply tragic though it was, it does seem that Fabio’s case was an isolated failing rather than a sign of any weakness in national policy. However, I take on board the hon. Gentleman’s comments and I have already made my hon. Friend the Under-Secretary of State for Health aware of the issue as the Minister responsible for long-term conditions, including eczema. I will also ask officials to look into the point raised in respect of NHS Direct and advice given regarding chickenpox and eczema.

I come now to how the trust acted after Fabio’s death. I am advised that staff from East Surrey hospital were in contact with the family at regular intervals after Fabio’s death to offer meetings to discuss his care. I have been informed that they were in touch on 16 occasions after the external review was received, and they were offered support, including access to independent advocacy, counselling, formal bereavement support and other psychological support, which was declined by the family, as is, of course, their right. However, it is clearly unacceptable that the parents received the external report nearly 10 months after it was received by the trust. Under normal circumstances, families should expect to receive the report within six weeks.

Perhaps I can gently say that I do not doubt that the trust was acting with the best intentions. My understanding is that it believed the report would have been too distressing for a grieving family to read, but there was a failure to explain that to the family that led to unacceptable delay and confusion, which was without doubt distressing in itself and an unintended consequence of a well-intentioned action.

Let me address the question of the coroner’s verdict. I have heard the hon. Gentleman’s concerns and want to make a few points. The coroner had access to the same information and the same members of staff as the external review panel. I therefore do not think that it would be right to conclude that the coroner’s verdict was affected by the timing of the external review. I obviously cannot comment on what advice Fabio’s family received about the inquest, but clearly if anyone is dissatisfied with the outcome of an inquest the verdict may be challenged by way of judicial review or an application may be made to the High Court for a fresh inquest. However, I will be happy to communicate to the Ministry of Justice, as the hon. Gentleman has requested, the concerns about the availability of the external report to the coroner.

In conclusion, the trust accepts that there were failings in the way that Fabio was looked after and I want to take this opportunity to express my most sincere apologies to Fabio’s family for that. It is imperative that when a tragedy such as this occurs we take a step back, learn from the mistakes and apply those lessons to prevent similar incidents from happening again. I believe that that is what is happening. The trust is taking measures to address the weaknesses that were found in Fabio’s care and management, the external review was extremely thorough and the subsequent action plan is a detailed response to address the weaknesses that were identified. I know that that can do nothing to repair the loss that has been suffered, but the actions taken since the tragedy will protect other children in the future.

Question put and agreed to.

House adjourned.