A fatal accident inquiry (FAI) has heard that the family history of a baby who died at Royal Aberdeen Children's Hospital should have “set off alarm bells”.
Michael Wilson was born on August 11, 2021, at Aberdeen Maternity Hospital and died at the Royal Aberdeen Children's Hospital on October 15, 2021, aged just two months old.
His older brother had a suspected inherited heart condition known as familial elastin atrophy (FEA) and died from complications after cardiac surgery in 2019.
Urgent surgery and heart scans
The inquiry heard that in 2021, Michael underwent urgent surgery for a hernia repair when he was two months old. The Lord Advocate considered the death happened in circumstances “giving rise to serious public concern”, and the FAI was ordered to explore the circumstances, focusing on the understanding and appreciation of the risk and complexities of his condition, information sharing between health boards and with family members.
Dr Adele King, a paediatric anaesthetist at the Royal Hospital for Children in Glasgow, was asked to review Michael's case and provide her opinion on how she would have managed his care. Speaking to the FAI on Friday, she said his family history would have given rise to a degree of uncertainty, which she believed warranted further investigation before surgery.
Dr King said Michael had an echocardiogram (echo) of his heart taken when he was a few days old, and a second scan a few weeks later. She said Michael “did not have a normal echo” result. The inquiry heard his neonatologist advised an urgent cardiology appointment in light of his scans and family history, even though he did not have symptoms.
Anaesthetists' concerns
Dr King said: “I appreciate that we had to do (the surgery) in a timely manner… but given the concerns that I can see, I think it could have maybe been delayed for a day or two for these things to be investigated. If I were presented with a baby with abnormal echo changes and a family history that is unknown, I would still be concerned about that. It wouldn’t really sit right – even though the baby was well, they’re still referring to cardiology for family history.”
The inquiry also heard from NHS Grampian consultant paediatric anaesthetist Dr Alan Barnett, who reviewed patient records before Michael underwent the hernia operation. He told the inquiry his records did not mention any family heart conditions. However, he understood the inherited heart condition that Michael's brother was suspected of having is a “very serious condition and commonly results in death under anaesthesia”.
Dr Barnett said: “If it (FEA) had been mentioned at any time, that would have set off alarm bells in my head. If, at any time, someone had even mentioned it in relation to Michael and his family, I would have been a lot more suspicious… It would definitely have altered my appreciation of the risk. The information sharing between health boards and between clinicians should be improved, and may have assisted me in this case.”
He said if clinicians in Glasgow had conveyed information regarding the family's inherited condition to clinicians in Aberdeen, or if the family had told him they were aware of a genetic abnormality, his management “would have been different”. “If that had been in place, things may have been different,” he said.
Communication gaps highlighted
Dr Alistair Baxter, a consultant anaesthetist and clinical director of surgery, anaesthesia, and theatres at the Royal Hospital for Children and Young People in Edinburgh, said he could not fault Michael's care team for the decision they made based on the information they had at the time. He told the inquiry it is “very easy to look at the writing that was on the wall” in retrospect.
He added: “At the time when Dr Barnett and Dr Davies met this child, I do not think they were prepared for what was going to happen.” Dr Baxter said the care team at Aberdeen would almost certainly have suggested the baby's hernia operation should be done in Glasgow if they had known the family had a history of suspected FEA.
“I think it’s a tragic event which has happened, but I don’t see – unless there had been real communication from either the Glasgow team or the parents or the GP, how Dr Davies and Dr Barnett were in any way able to know what was going to happen,” he said. “If information had been passed on about the severity or the potential severity of this condition to his parents, and if that had been signed in a letter either from the GP or from the parents, then I’m absolutely convinced that both Dr Davies and Dr Barnett would have stopped before they undertook this case and referred to Glasgow.”
He said if Michael's parents had been told in stark terms that the suspected hereditary condition carried a risk of death to any other siblings, he is “absolutely convinced” they would have mentioned it to Michael's anaesthesiologist in 2021. He said information sharing across borders and health boards is “very difficult”.
Dr Baxter added: “For this reason, the only way I could see this being prevented was a very significant letter being sent both to the GP and the family to highlight that any future siblings have a risk of death.”
