Patient Number KG6545
DATE OF BIRTH 25.5.00
Address Ilford, London UK
2) Documents and lists of names involved
3) Facts of the case
2) Facts about Trisomy 18
3) Ethical Considerations of Trisomy 18
4) Trisomy 18 Patients – Futile cases or
1) Emergency Protection Order – justified
2) Basis for Emergency Protection Order
3) Medical Opinion on Emergency Protection Order
4) Further medical evidence
6) Medical and Factual Inaccuracies in the documents
of the EPO
Personality Conflicts and Communication
Imputation of Psychiatric Illness
Confidentialiy and Consent Issues
1) Was the patient dying?
2) Withdrawal of treatment and Do not Resuscitate
3) Cause of death
1) Other Concerns raised by the family
MEDICAL INVESTIGATIONS UK
P.O. Box 8553, West Midlands, B86 2BS
Patient Number KG6545
DATE OF BIRTH 25.5.00
Address, Ilford, London UK
1. We have been asked to formulate an independent
report regarding the circumstances of the death and medical treatment of Sunaina Chaudhari (deceased). This has been requested
by Ms Sadhana Chaudhari and Rajesh Kumar Chawla, Ms Neelu Berry and their legal advisers.
2. The aim of this report is to assist in the medical
aspects of the case and elucidate issues which may be of legal significance. Our
report is an objective assessment using the comparator of “normal medical practice” in the United Kingdom.
3. We are an organisation which provides independent
advice on a wide range of issues affecting individuals who have complaints against the NHS health service. As a team of doctors
we either offer advice to resolve disputes quickly or provide independent advice on cases, both medical negligence and criminal
in nature, for the police and individuals.
4. Our objective is to direct the individual to
the achievement of natural justice.
5. We are a voluntary organisation. Our aim is
to provide a fair and impartial view of this case. We are dedicated in the pursuit
of justice and thus have waivered any charge in compiling this report. In addition,
we hope to clarify the concerns raised by the family of the child. We have provided an objective opinion of the circumstances
surrounding the care and death of the above patient. We have thus provided a truthful and honest account of clinical practice
with comparisons made to national directives in the United Kingdom.
6. The current report has been formulated by UK
medically trained doctors. The main body of the case has been from Dr Rita Pal,
BSc MBBS (Medical ,Pyschiatry Social and Legal aspects of the case) and Dr BR Pal, MBChB, MRCP(paed), FRCPCH (Paediatric and Neonatal aspects of the case)
7. May we take this opportunity to convey our condolences
for the death of their child under circumstances that no parent should have to endure in the United Kingdom.
We owe respect to the living - to the dead we owe
only truth. Voltaire
8. The events have caused unnecessary distress
to the parents and relatives at a time when their only living child was dependent on the social and health care providers
of the NHS Trust. This has severe repercussions in causing mistrust, breach of human rights and may potentially lead to long
term trauma induced by the direct actions of these institutions.
We wish to state that no parent should be removed from their child in the last ten days of the child’s life by
the force of the police and the authorities. This is contrary to the ethics stipulated in the medical and legal fields.
Article 24 of the Convention on the Rights of the Child states that:
States Parties recognise the right of the child
to the enjoyment of the highest
attainable standard of health and to facilities
for the treatment of illness and
rehabilitation of health. States Parties shall
strive to ensure that no child is
deprived of his or her right of access to such
11. We shall endeavour to provide an evidence based
report to verify the events of the case in medicine, ethics and law with particular note to the above. This case is complex given that there have been multiple clinical and social teams involved.
We have therefore considered a wide range of issues with respect to
a) Mismanagement by Social Services personnel
b) Mismanagement by King George Hospital personnel
c) Mismanagement by all clinical teams
d) Illegal obtaining of the Emergency Protection
Order by Medical and Social Personnel
e) Abuse of General Management of the Parents/child
f) Abuse of Clinical care and Risk management of
g) Lack of Consent
h) Breach of Confidentiality
i) Wrongful imputation of a psychiatric illness
We refer to a diverse range of current documentation which elucidate the present thinking of the “reasonable
clinician”. The sources of our documents are from the leading authorities in our field, namely the British Medical Association,
the General Medical Council and the Department of Health.
14.Provision of Documents
Documents relied upon
In preparation of our report, we relied on bundles
of documents provided including:-
a) Medical Records for Sunaina Chaudhari (and Sadhana
b) All documentation involved in obtaining the
Emergency Protection Order
c) Redbridge Protocol For Emergency Protection
d) Contemporaneous notes made by the family during
e) Sparse Social Services documentation
f) Post Mortem Reports by Professor Risdon and
g) Toxicology Reports
h) All letters written by the Family with respect
to a complaint to Redbridge NHS Trust
i) Video Evidence of Sunaina Chaudhari elucidating
her normal activities during the period when the “ Do not Resuscitate” order was given.
j) Substantial contact and questioning of the family
to discern the facts of the case. We have been unable to question the authorities due to their constant refusal to answer
our questions posed via the family. They have recently refused co-operate in our investigation.
LIST OF STAFF / ROLES
KING GEORGE HOSPITAL
Chief Executive King George Hospital
Trust Solicitor King Georges Hospital
Dr David Robinson
Dr Anand Shirsalker
Sister Angela Judd Sister on Clover ward
Nurse provided to Sunaina during 26th October 2000
Director of Nursing
Dr Thomas Rager
Dr Sanjay Sahi
Dr Kathy Padua
Dr Naomi Hancox
Dr Rachel Windsor
Sen paed Registrar
GREAT ORMOND STREET HOSPITAL
Dr Mark Peters
GOSH NICU Consultant
Dr Andy Petros
GOSH NICU Consultant
Dr Mark Kenny
GOSH NICU Consultant
Consultant Respiratory Physician
MENTAL HEALTH SERVICES Goodmayes Hospital
Director of Mental Health, and Head of Immediate Response Team (now called 24/7 team)
Locum systemic psychotherapist
Child Protection Nurse Specialist
KENWOOD GARDEN & HOME CARE TEAM (part of London
Borough of Redbridge)
Manager Kenwood Garden
Dr Sarah Luke
Community Nursing Team
Community Nursing Team
LONDON BOROUGH OF REDBRIDGE
Chief Legal Officer & Council Solicitor
Redbridge Legal Department
Teresa Walsh Jones Social Worker & Child Protection Enquiries Team Manager C & F Team
Social Worker & Manager of Children with Disabilities Team C
& F Team
Social Worker & Child Protection Officer C & F Team
Social Worker Principle Officer C & F Team
Social Worker Emergency Duty Team
16.FACTS OF THE CASE
19 Aug 99
Date child Conceived
05 Jan 00
1st antenatal Scan Ultrasound scan at KGH –Diaphragmatic
hernia on foetus
of diaphragmatic hernia
06 Jan 00 21wk
Gestation UCH Ultrasound scan & Amniocentesis
26 Jan 00
Gestation second USS at University College London
18 Feb 00
Gestation Echocardiography at GOSH
24 Feb 00
USS at UCH
22 Mar 00
Gestation Robinson refused DH operation
28 Mar 00
25 May 00
Chaudhari born at KGH at 00.10hrs
26 May 00
taken to GOSH for Echocardiograph 15.00hrs
26 May 00
met surgeon at GOSH about DH operation – no decision
30 May 00
met geneticists at GOSH about DH – no decision
01 Jun 00
DH operation performed on day 8 at GOSH. Stomach perforation found and repaired
08 Jun 00
Return to King Georges Hospital SCBU
21 Jun 00
Started to wean off CPAP
18 Jul 00
Second discharge planning meeting
19 Jul 00
Off CPAP – on low flow oxygen
30 Jul 00
First set of vaccines
01 Aug 00
3rd August 2000 23.8.00
Visit to hospital –concern about airway secretions
10th August 2000 2300
Visit to hospital
Blood noted in NG Aspirate
12 th August 2000
Visit to hospital
Increase in secretions
13th August 2000
Visit to Hospital
Lower respiratory Tract Infections
Visit to Hospital – blood in stool
Incident 1 Oxygen – Clover Ward
Responsibility for the patient lies with the Trust
as soon as the child enters the premises – this is thus the nursing staff and doctor’s responsibility NOT THE
16th August 2000
Incident 2 Redbridge 16 Aug 00 Oxygen incident with ambulance man during hearing test appt reported to 999 Police
22 August 2000
07 Sep 00
OPD appt with Shirsalkar – VSD closed
15 Sep 00
Second set of vaccines & first dose of Polio
26 Sep 00
x-ray – both lungs same size, no sign of lung disease
25th September 2000
Visit to hospital
Incident 2 Oxygen cylinder
This again was merely an oversight and in any event
the TRUST is responsible for provision of oxygen once the patient enters the hospital
Admission To Clover Ward King George Hospital 01
Oct 00 Admitted to KGH with throat infection – Prescribed well by Dr S Sahi
02 Oct 00
medication & CPAP stopped by Dr Shirsalkar
04 Oct 00
with Ranitidine x 10
5th October 2000
First Letter to Chief Executiv
5 Oct 00
Doctors and nurses ignored desaturation alarms for 6 hours Sats 38%
Complaint to Chief Ex Peter Murphy
Complaints against mother
10 Oct 00
hours of meetings - Psycho-social meeting first followed by strategy meeting called at short notice – no cause for Sectioning
13th October 2000
to Addenbrookes requested by local MP – date offered 23 Oct
14th October 2000
Awaiting transport for transfer to GOSH
19 Oct 00
of application to High Court for declaration to withhold treatment
20th October 2000
20 Oct 00
Drs Robinson & Shirsalkar visit GOSH intensivists
Discussion with intensivists at Great Ormond Street
20 Oct 00
Ex-parte hearing at Redbridge Fam P Ct Orders for EPO & warrant granted at 23.00hrs
Outcome plan “ obtain a restriction order
to exclude mother , father and aunt from ward” D331
Emergency Protection Order Obtained 24.55
Served on Mrs Chaudhari in the presence of 2 police
officers by Teresa Walsh Jones
21 Oct 00
01.00hrs orders served on mother at KGH by two Police Officers and 2 social workers (Teresa Walsh Jones & Maria
Murphy). All medication & CPAP stopped.
Frusemide continued without blood monitoring. Water stopped
23rd October 200
Great Ormond Street
95% saturated on nasal cannula oxygen
Resp 40 beats per minute
Chest Clear ( D 360)
DNR provided and signed for. 23 Oct 00 Assessment by GOSH intensivists at KGH – parents excluded at the last minute
1700 Meeting with family and King Georges Hospital
staff ONLY – Informed of the unilateral decision.
Dr Petros and GOS intensivists
They did not meet with the parents . There is no
record of this. No discussion regarding the DNR notice
23 Oct 00
Blister on lower lip
24 Oct 00
Bruise under tongue
24 Oct 00
Mum visited solicitor Andrew Beale to apply to overturn EPO
25 Oct 00
KGH doctors prepare to discharge Sunaina home as well enough
26th October 2000
26 Oct 00
Parents in Court to overturn EPO with Dr Robinson and Trust Solicitor Caroline Harrison as witnesses for the London
Borough of Redbridge. Guardian Ad Litem called late.
Death of Sunaina
Events written below
Post Mortem by Professor Risdon
17. Mrs Sadhana Chaudhari is a teacher by profession
with the qualifications BSc and PGCE. Please refer to the family documentation where details are listed by the mother regarding the loss of her only child. Her husband
Mr Rajesh Chawla is a Yoga therapist recently resident in the UK. His mother
tongue is Punjabi.
Sunaina Chaudhari was the child of an Asian family who are originally from India. This family is very close with her
Aunt Neelu Berry providing advocacy and support. This also confirms as with most Asian families that an extended family support
exists and differs from the modern nuclear British family. The child should be considered in the context of her natural environment,
which is her Asian culture. The extended family in this case is very inherently supportive.
From the evidence presented to us, Redbridge NHS Trust did not provide an interpreter for Mr Rajesh Chawla until a
formal complaint was made in October 2000 by Sadhana Chaudhari. The omission
of an interpreter during several important discussions about the welfare of their child resulted in his exclusion in the decision
making process. ( Refer to statement by Mr Rajesh Chawla)
20. This family are devout Hindus. This religion
involves culture and customs that maybe misconstrued by the health professionals who lack insight. Hinduism is a culture and a way of life. Individuals who lead their life in accordance to the Gita have
beliefs in the “sanctity of life”. This should not be overlooked. We note that at no time was there any discussion
regarding the implication of religion which should be part of the decision making process. As a comparator, the Jehovah’s
Witness religion is greatly debated in the medical profession. The treatment of a child who was Jewish is considered by Dr
Inwald and Dr Petros in their article
( BMJ, 6th May 2000).(Appendix 3C). We note that in this case the Rabbi’s opinion was sought. In this particular case, the Hindu opinion
was not taken into account. There has been no debate or consideration of the
implications of Hinduism; however, this aspect should not be dismissed. In the
very words of Dr Petros and Dr Inwald themselves “ The aim of intensive care is to treat the family, not just the patient”
21. This child was very much “wanted” and “loved” by her immediate and extended family. This is demonstrated by the concern they showed in caring for her.
“S1 states “ After a year of trying
to conceive without success because of work pressures, I felt that a break from work might do the trick. So in April 1998,
I requested leave of absence without pay for one year so that we could go for a long break in India and try for a baby”
From this we infer that Mr and Mrs Chaudhari desperately wished for a child.
“ On my return I went to see my GP with our
problem who referred me to a fertility clinic at Queen Mary’s Hospital in Sidcup, Kent. I did not have a period in September
1999 and a home pregnancy test proved positive.
“ WE WERE BOTH THRILLED “
23. Having suffered long term fertility problems, this child was all the more wanted despite
24. In making clinical or legal decisions it is
imperative to take into consideration the social aspects to reach a fair and balanced judgement.
FACTS ABOUT TRISOMY 18
25. Appendix 1 illustrates a summary of the salient
features required for any professional. It provides the most succinct overview of the care required from healthcare professionals.
It is vital that this is read by all those who read this report to familiarise themselves with the essential nature of Trisomy
26. EVERY CHILD IS AN INDIVIDUAL NOT A STATISTIC.
“About 10% of children with the full trisomy
13 and 18 live beyond the age of twelve months, but children are not statistics and in many circumstances accurate predictions
of life expectancy are not possible.” SOFT
FROM SOFT GUIDELINES Professor John Carey
is important to recall that about 5-10% of children with these syndromes do survive the first year of life, thus, the condition
is not universally lethal as sometimes presented by health professionals.
the developmental disability in children with trisomy 18 and 13 is significant, it is important to recognise that children
do advance to some degree in their milestones. They can interact with their families, smile and acquire some skills, such
as rolling over, self-feeding, etc. if they survive infancy.
c) Families in these situations appreciate the
opportunity to participate in decisions involving the care of their children. If you have any families dealing with the issues
discussed, please keep SOFT in mind.
28. Failure of utilising appropriate mortality
IT IS IMPORTANT TO NOTE THAT THERE HAS NOT BEEN
A STUDY ON THE SURVIVAL OF TRISOMY 18 SINCE 1994. IN OUR EXTENSIVE RESEARCH IT WAS DIFFICULT TO DETERMINE ANY RECENT STATISTICS.
a)Sunaina was born in the year 2000
b) Her survival was predicted by the statistics
of 1994, which is six years ago.
c) Medical technology has advanced since 1994.
More intervention may have resulted in survival of many more individuals
d) Great Ormond Streets Letter “There is
apparently 11 reported cases in the world wide literature who survived to teenage years”. We suggest that this is inaccurate
since the oldest living person was not a teenager but aged 40 and in addition there are many cases above six months of age.
e) It is noted that SOFT have 360 members who are
survivors over the age of six months (please see appendix 3)
f) The oldest survivor was 40 years old.
g) These are members just in the USA. It is predicted
that the numbers are far greater worldwide
h) The survival of females is greater than males.
THIS INFORMATION WAS NEVER PROVIDED TO THE PARENTS, MR and MRS CHAUDHARI
A5a states that “ as we all know there is
a 30% mortality rate at one month of life, 60% at two months and 98% within one year. (Paediatric Intensivists, GOS)
Given the most recent data, it is not unreasonable to postulate that due to either the lack of statistics pertaining
to year 2000 or provision of information from the most recent expert source (SOFT),
the figures of survival quoted here by Intensivists, were outdated and lacked the best evidence-base available. In addition the figure presented is not referenced. The opinion of this patient being a “ futile”
case is based simply on outdated and historical attitude and belief.
This confirmed the ingrained professional prejudice
displayed by medical opinions of GOS intensivists for this case.
Furthermore, throughout the case notes and referral letters, the quoted statistics of mortality have relied erroneously
on assumptions on Trisomy 18 outcome based purely on that predicted during pregnancy or at birth.
In this case, Sunaina Chaudhari lived to the age
of five months. It is stated by Professor Carey (AB82) who is a renowned specialist
in this subject that
“ … the chance to survive to a year
are higher than they were at birth” .
From this we conclude that her survival was greater that stipulated in the figures quoted by the Intensivists of Great
Ormond Street on October 20th 2000. However the fact that the “ chance
to survive is higher than at birth and this value is unknown due to no research on this subject “ was not explained
to Mr and Mrs Chaudhari. Their figures are incorrect at five months of age. Some
studies have indeed shown a greater survival at 6 months in comparison to previous studies done. EG
“However, we had a significantly greater
survival at 6 months (9% in Utah versus 3% in Denmark) and 1 year (5% versus 0 in the 3 studies “(Am J Med Genet 1994
Jan 15;49(2):170-4 Root S, Carey JC)
ETHICAL CONSIDERATIONS OF TRISOMY 18
The National Health Service directives prides itself in ensuring equal access to healthcare for every individual. The
treatment of Trisomy 18 patients and their families is no different. We thus
refer to the NHS Plan listed below
The NHS Plan - opportunities for improving health
and access to health services for black and minority ethnic populations. This is a working document, which we refer to. (Department
‘Services must be delivered with regard to cultural appropriateness’.
1. The vision: a service designed around the patient
This is an opportunity to refocus services so that
they begin from the
individual, needs and characteristics of patients.
This means taking full
account of every patient’s ethnic cultural
and religious background.
1.9 Advice to enable people to take care of themselves
and their families
will need to respect cultural and religious differences
.1.18 Intermediate care services will need to provide
for the needs of all
patients including those from minority ethnic groups
respecting the full
range of cultural and religious practices.
1.21 NHS standards should include sections on cultural
competence, with a
common means of assessing this, including patient
and user surveys.
35. We understand from the documents that the parents
were strongly advised to
“ terminate the pregnancy “ from the
outset. This was in direct conflict to the parents wishes and religious beliefs”
“We felt pressured by doctors” comments
such as the fetus will die inside me, the fetus will not make it to full term, it will die during labour and that if it was
born alive that it would only live for a few hours”
“ Due to our strong religious beliefs that
the baby was a gift from God, we continued with our pregnancy” Mr and Mrs Chaudhari .
36. Professor Charles Rodeck FRCOG 2/01/2000 ( R7)
“She was seen by Ms Wright (paediatric surgeon)
The diaphragmatic hernia itself carries a mortality
of 50% with Edwards’s syndrome this is increased such that the baby is very likely to die shortly after birth. It would
not be appropriate to operate in these circumstances…”
NB It should be noted that the baby survived the
“The couple wish to continue the pregnancy
and for the baby to managed as appropriate at birth”
“ They were seen by Dr Hawdon (Consultant
Neonatal Paediatrician at UCH) who explained that in the circumstances neonatal intensive care would not be appropriate. The
parents disagree and do not wish to be booked at UCH”
Comment: From this we infer that from the very early stage of pregnancy,
there was a clear divide: between the clinicians to limit intervention and enhance permissive mortality of the foetus and
parents’ wishes to protect their unborn child. There was no recourse to reach agreement. This nurtured a fundamental
deep mistrust between medical professionals and the family.
37. We thus conclude that at no time previous to
or during the treatment of this child were the
Cultural differences taken into account
Religious beliefs considered
The parents faced negative approaches from the clinicians involved with very little explanation or discussion to resolve
this differing opinion.
d) In these circumstances, it would be a natural
reaction for parents to perceive that, as the medical professionals had condemned their child, they would not provide objective
or positive opinions towards the care of this child.
e) This naturally caused disharmony and friction
between the doctors/nurses (caregivers) and the parents (care-receivers). All
reactions of the mother must therefore be taken in this context.
f) It is accepted that the clinicians wished to
terminate their child, did not wish for any intervention and in general had in effect doomed a child based only on the statistics
regarding Trisomy 18. Each child has a right to be treated as an individual.
Not all Trisomy 18 children die within a few weeks or months of life. ( See Section
g) There was a distinct lack of communication with
regard to the specialists who were suggesting the death of their child.
A few directives are observed below. These show
the standard of practice required for the “ reasonable doctor”
4.3. Good communication
Good communication between patients and doctors
is essential to effective care and relationships and trust. It involves:
* listening to patients and respecting their views
* giving patients the information they ask for
or need about their condition, including its causation and relationship to work (where known), its treatment and prognosis,
and any remedial steps that can be taken to limit its effects or prevent recurrences
* giving information to patients in a way they
If a patient under your care has suffered serious
harm, through misadventure or through a mistake or omission, you should act immediately to put matters right, if that is possible.
You should explain fully and promptly to the patient what has happened and the likely long- and short-term health effects.
When appropriate you should offer an apology.
Natural History of Trisomy 18 and 13. American Journal of Medical Genetics 49:175-188(1994) Bonny Batty, Brent L Blackburn
and John Carey
“ There also tends to be skewing of information
toward the extreme negative, with families often being told that their child has no chance of survival, and more importantly,
little chance of meaningful interaction with their families. “.
Dr Una MacFadyen Paediatric Consultant and Medical Adviser to SOFT UK
“ As always the need for communication is
paramount among all professionals involved. Anyone of us may see only a few babies with Trisomy and may not have the latest
information to hand. “
Developmental Disabilities Digest
“It is equally important to remind parents
that 5-10% of children with trisomy 18 do survive the first year of life, and those who do survive usually advance to some
degree in their milestones and interact with their families in many ways. Thus, the outlook is not necessarily hopeless. For
long-term survivors, many of the early problems become more manageable as physicians, specialists, and parents’ work
together to find appropriate solutions. In any case, it is important to focus on the unique medical circumstances of the child
and the personal feelings of his or her parents.” http://www.ddhealthinfo.org/ggrc/doc2.asp?ParentID=3183
Golden Gate Regional Center
120 Howard Street, Third Floor
San Francisco, CA 91405
Theodore A. Kastner, M.D., M.S.
Felice Weber Parisi, M.D., M.P.H.
Romie H. Holland, M.D.
Patrick J. Maher, M.D
TRISOMY 18 PATIENTS – FUTILE CASES OR NOT?
Throughout the literature it much be said that very few studies have been conducted on Trisomy 18. In the absence of
recent research it is important to provide the reader with an overview of the quality of lives that these children lead. Great Ormond Street and many other institutions would wish us to believe that these
cases are futile. Is this necessarily so? We would like to state that 10% of
children might indeed survive according to the 1994 research and the attitude
of futility would lead to the death of this 10 % who indeed may survive. It is very difficult to predict survival of an individual
This is quoted by the health professionals involved in the care.
R1 and R2 Letter from Dr Louise Wilson to Mr and
Mrs Chaudhari 1st June 2001
“ We do not fully understand why occasional
children with Trisomy 18 survive much longer than the other children”
“ In any individual child it is very difficult
to predict their survival… “
“ From our discussion I do fully understand
your wishes to give Sunaina the best quality of life that you are able to and as much love and care for her family as possible”
Letter from Dr A Petros (0515) Paediatric Intensive Care. Great Ormond Street London
“The exact prognosis in this case is uncertain
but it is unlikely she will survive more than a few months
We would like to state that during our research we have found many children leading fulfilling lives and whom their
families care for. There are some children who have been worse than Sunaina Chaudhari
with multiple problems, yet they continue to live well. There are many misconceptions
about the quality of life these children lead. It must be understood that these children are not in a “ persistent vegetative
“ state. They are able to interact with the environment and their families. We demonstrate this by a selection of the numerous cases that have defeated the medical
professional’s attitude of futility.
Professor I Young, Department of Clinical Genetics.
City Hospital Nottingham
“ Surviving children of Edwards syndrome
have marked developmental and motor delays. Their verbal communication is severely impaired, and is limited to a few single
words at best; but they are mostly aware of their environment and are able to communicate some of their needs non-verbally.
They continue to acquire new skills over time and develop some understanding of language. A few can walk with assistance.
Overall, their skills in daily receptive language and social interaction tend to be higher that their motor and expressive
CASES AS COMPARATORS
From: Andreas and Darcy Nahme <email@example.com>
Sent: 15 May 2001 02:45
write to you as a mother of a 5-month-old infant that has trisomy 18. I read
the article you speak of and find it quite appalling. My daughter is in no way "incompatible with life". As a matter of fact,
her cardiologists just tried to be able to perform open-heart surgery to
her heart defects, but due to some unforeseen circumstances, was not able to. She did have a heart catheritization and went
on a ventilator and came off within an hour after the procedure. She was transfused with appx 70 cc of compact red blood cells.
This is just one
of what kind of treatment my daughter gets here in the US. I know what could
possibly happen to Savannah, but I also know that shebrings me great joy and unconditional love. No one in their right mind
will ever choose my daughter’s outcome. She is here today and is proving doctors wrong each and every day. I was so
saddened when I read that
Please feel free to visit my website, it is listed in my signature line. Good luck and if you need any further information
be glad to help as much as I can.
Christi, TX USA
parents of Savannah Kristyne (full T-18) born 12/12/00
Comment – This is a case that is considerably
worse than Sunaina yet she was not met with a Do Not Resuscitation Order. Why?
Other surviving children
These are a few children with similar stories.
They are a selection of the many.
See Appendix 2A for complete details
Kirsten'sbattle with trisomy 18 helps the Guptills see every day as a miracle
Kirsten, all 3 feet, 221/2 pounds of her, turns
6 on April 2.
Kirsten had similar abnormalities to Sunaina.
This patient is still living. In addition, we see
that she has proved medical professionals wrong.
Case 3 Details in Appendix 2B
Our daughter Kameron has full Trisomy 18. She was
born May 8, 1997 in Charleston, South Carolina. We knew of Kammie's diagnosis at about twenty-four weeks into the pregnancy.
Kammie has no heart defects, but she is globally delayed. She is terribly spoiled by her big brother (Derek - 14) and big
sister (Kelsey - 12). We are working on prop sitting and started three-year-old public school in the fall.
Kammie has under-developed thumbs and is currently
on a diet! She is fed through a Mickey button and receives Pedisure with Fiber, essential fatty acids, and a laxative tea.
Her weekly therapies include speech, occupational, aquatic and physical
The above illustrates that many cases do survive to older age and this would be the best current evidence. In addition, research should provide assistance but certainly not be the only factor in deciding a person’s
EMERGENCY PROTECTION ORDER
JUSTIFIED OR NOT?
The Emergency Protection order was obtained by on the 20th October 2000 by the Respondent’s Solicitors.
It states that the (C16) Court directs “
that contact by the parents shall be as directed by the local authority. The court excludes Mrs Neelu Berry with contact with
Comment: BY DEFINITION THIS ORDER DOES NOT INCLUDE CONSENT
FOR MEDICAL TREATMENT.
In Dr Petros’ letter from Great Ormond Street (25th October 2000)(A2B) states that
“ In these sad cases we would recommend “family centred palliative care”
Yet D331 20/10/00 it is listed
“ Discussion with intensivists at Great Ormond Street. Outcome plan
To obtain restriction order to exclude mother, father and aunt from ward”
This was the recommendation of Great Ormond Street
Children’s Hospital. On the basis that Great Ormond Street consider the prognosis poor we will continue to discuss the
The definition of family
“A group of people connected by close relationship.
A family is usually limited to relationships by blood or marriage.
By virtue of this definition Suniana Chaudhari’s
family were denied to right to be at her side by Great Ormond Street and King Georges Hospital.
This action of EPO contradicts the directive provided
by Great Ormond Street itself.
Great Ormond Street further acts contrary to its own advice it their letter GO33 25th October 2000 (same day as the
above) where they supported the actions of the Emergency Protection Order by writing to Ms Caroline Harrison (disclosing details
of the patients and family without their consent). Data possessed by Great Ormond Street
is governed by the Data Protection Act 1998 . No consent was obtained by GOSH from the family in order to write to
solicitors of the King Georges Hospital. A solicitor is not an individual who is part of the “ care team” . No
consent was obtained that was written or verbal.
Great Ormond Street seems to contradict their own recommendation in supporting the removal of the parents from the
care of their child while previously suggesting “family centred palliative care” in the letter to Dr Robinson.
Comment: We feel that there should have been a duty of care of Great Ormond Street to speak to the parents at this
time to deduce the correct events as opposed to disclosing documents after making a decision on hearsay (please see discussion
Other directives for the care for patients with Trisomy 18
a) SOFT DIRECTIVE FOR PATIENTS
“Where there are major life threatening problems
and the future of the baby seems hopeless, it may not be right to provide the highest level of life saving skills, but the
decision not to give intensive care to prolong the life of a very sick baby does not mean that loving care is withdrawn. The
child can be kept comfortable and peaceful with much of the nursing care being provided by the parent or parents and supported
by the medical staff”.
b) The European Convention on Human Rights
7.35 Article 8 of the European Convention on Human Rights states that:
(1) Everyone has the right to respect for his private
and family life, his home and his correspondence.
(2) There shall be no interference by a public
authority with the exercise of this right except such as in accordance with the law and is necessary in a democratic society
in the interests of national security, public safety or the economic well-being of the country, for the prevention of disorder
or crime, for the protection of health or morals, or for the protection of the rights and freedoms of others.
BASIS FOR EMERGENCY PROTECTION ORDER
We wish to provide a medical perspective of the
basis of the order.
a) It should be noted that Mr L Rogers is a lay
justice of the peace with no legal training.
b) No documents pertaining to Mr and Mrs Chaudhari’s
complaints about the hospital were provided, although available.
c) We note that the justice of the peace heard
i) Maria Murphy , Social Worker
ii) Dr Anand Shirsalker
iii) Dr David Robinson
Minutes of the meeting of the 22/8/00 and 10/10/00 were taken into account. We have taken the liberty of discussing
the factual accuracy of these meetings.
a) At no time were the family informed of the meetings
nor the intention of an Emergency Protection Order.
b) There was no assessment by the social workers.
There have been no entries in the medical notes or documents of assessment attached to the Emergency Protection Order application
(There have been no assessments as stipulated by UK directives)
c) We have been unable to peruse the Social Services
Our medical opinion on the documentation included in the Emergency Protection Order application are as follows: -
Social services owe a duty of care to carry out a full assessment of needs. This includes interviews with all the professionals
and the family concerned. The main directive of practice is stated in the Redbridge Protocols for child protection. These
are based on national directives provided by the Home Office.
The leading document which is the directive in this case is from
of Health Home Office
Department for Education and Employment
Working Together to Safeguard Children Published
in 1999 and thus in force in 2000 ( APPENDIX 5)
This document is intended to provide a national framework within which agencies and professionals at local level -
individually and jointly - draw up and agree upon their own more detailed ways of working together. It reflects the principles
contained within the United Nations Convention on the Rights of the Child, ratified by the UK Government in 1991. It also
takes account the European Convention of Human Rights, in particular Articles 6 and 8.
“Good practice calls for effective co-operation
between different agencies
and professionals; sensitive work with parents
and carers in the best interest of the child; and the careful exercise of professional judgement, based on thorough assessment
and critical analysis of the available information.”
The legal representatives will tackle the other aspects of the Emergency Protection Order. It will suffice to add that
an authority is bound by law to comply with The Emergency Protection Order (Transfer of Responsibilities) Regulations 1991
(section 3) where many factors are listed .
On writing this report, we have not consulted any documentation from the Social Services. On questioning the family,
we ascertained that at no time did interviewing either the immediate or the extended family take place They were not aware that this was a Child Protection issue until the order was served on the 20/10/00
None of the family members were informed. No other avenue was sought.
Under the Home Office recommendations, the local authority is under a duty to make enquiries. This was clearly not done. (
see Appendix section 5 on Significant Harm)
On perusal of the documents listed in Appendix 2, there is no evidence medically or otherwise that the parents would
have caused significant harm to the child. This is evidenced by the following factors
a) In discussion of the background of the family,
we note the child was loved and wanted. In fact throughout the records individuals
were pleased with the care she provided. This was Mrs Chaudhari’s first child whom she did not terminate and whom she
has attempted to fight to protect. This is noted in her letters to the Chief Executive where her concerns for the care of
her child are made clear (5th October 2000).
following contradictory entries to the indications of an EPO were made in the Social Worker’s statement to the court
Section 18 At the culmination of this meeting a
clear view was not provided by hospital staff, which would suggest that Suniana had suffered from significant harm as a result
of care, provided to her by her parents. Furthermore, hospital staff did not
provide an opinion that reasonable cause existed to believe that Suniana was likely to suffer significant harm as a result
of the care provided by her parents.
Section 20 ‘I received a response to my letter on the 23.10.00’.
The letter from Dr Shrisalker 19.10.00 states “ taking a birds eye view of the whole situation, I do not think there is a
child protection issue at the present time “.
Section 25 “During the hearing Dr Shrisalker indicated that Mr and
Mrs Chaudhari had recently suggested that they may remove Suniana to a different hospital as they were concerned about the
appropriateness of the care provided at King George Hospital.
D415-D416. We note this document is both typed and written on the 25/10/00.
It is listed as “ Care Plan for Sunaina Chaudhari”
Point 1 of this document states “ To go home
on low flow oxygen via nasal cannula”
From this we infer
Dr Anand Shirsalker wished to discharge this patient to the family. His decision was made on the 25/10/00 (on the 5th
day of the Emergency Protection Order)
ii) If she was in danger of “significant
harm” – it does not seem rational or logical that this doctor would have made the decision to send her home
iii) Clearly in his professional opinion, the parents
were able to take care of the child and it was safe to do so, that Dr Shirsalker was prepared to discharge the patient into
iv) This action contradicts his own opinion of
the 20th October2000 when he deemed an EPO was needed. These actions are illogical. To assume that on the 20/10/00 the child
was in impending danger, so much so that an Emergency Protection Order was taken out at middle of the night (23.00hrs) without
the parents’ knowledge or prior discussion.
Comment: We conclude therefore that the patient was never actually
in any danger from her family
73.FURTHER MEDICAL EVIDENCE INCLUDE THE FOLLOWING
a) Parents cared and were committed to the well-being
of their child, evidenced by the following
Mother and father explained that they would like to offer everything for the baby to give a chance. They fully appreciate
the poor prognosis and the possibilities of post op complications. However since the other option is death anyway, they would
like to be given a chance and they are very committed to that”
“ Mum cuddled baby and breast-fed baby”
Page 2 9/6/00
“ Mum and dad cuddled baby for one hour”
C34 “Mrs Chaudhari appeared to be control
whilst caring for Sunaina at home and provided a good level of care to Sunaina
D114 13/6/00 “ Mother cuddled the baby for
a long time and seemed very happy since baby was put on nasal prongs “
Dr Shirsalker noted that “ It was generally observed that Mr and Mrs Chaudhari
provided a good level of care to Sunaina whilst she was being cared for at home”
(meeting 10.10.2000) meeting.
Dr Robinson “ … it is difficult to
confirm that Sunaina has suffered or is likely to suffer from significant harm as a result of care provided by Mr and Mrs
“ Mrs Chaudhari presented as calm co-operative
during visits undertaken by Pam Hanton. Her care of Sunaina was EXCELLENT. Mr Chaudhari’s care was “ superb”
and he spent time singing, and providing body message to Sunaina which she enjoyed “ ( Meeting 10.10.00)
74. TERESA WALSH JONES
“ It has been stated that Mr and Mrs Chaudhari’s
care of Sunaina has been satisfactory when she was at home”
“ No medical view or opinion has been provided
at the meeting to suggest that Sunaina has suffered significant harm as a result of Mr and Mrs Chaudhari’s care “
“ No concerns were noted in relation to the care provided to Sunaina whilst she was at home.
“ mother did all cares “
A D120 17.6.00
“ parent in and mum does all cares “
D162 10.7 .00
“Baby care for by Dad in the afternoon. All observations satisfactory.
These are examples of the recordings throughout the medical records. They show good mother to baby bonding, concern
for the child, and protective parental qualities expected of any reasonable parent.
2.18, 2.25, 2.26, 5.11, 7.23 and Other Cultural factors were not considered by the social services team. This is a
failure of their duty of care to the family and the child.
WE CONCLUDE THAT FROM THE ABOVE EVIDENCE PRESENTED
THIS CHILD WAS NOT IN DANGER OF SIGNIFICANT HARM AS ALLEGED.
FAILURE OF SOCIAL SERVICES IS A DIRECT RESULT OF
a) Failure in communication with the family
b) Failure to conduct a complete assessment to
take all factors into account
c) Failure to assess the concept of “ significant
d) Incomplete documentation presented to the court
which has misled proceedings
e) Failure of duty of care to ensure protection
of the human rights of the child and family.
MEDICAL AND FACTUAL INACCURACIES IN THE DOCUMENTS
OF THE EMERGENCY PROTECTION ORDER
WAS THE MEDICAL INFORMATION PROVIDED RELIABILE IN FACT?
There have been a number of allegations made by
the staff at Redbridge NHS Trust and Community teams. We would like to examine
whether there is any scientific basis for these allegations and whether they constitute “ significant harm”. This
is because these allegations were used to gain the Emergency Protection Order.
The MAIN ALLEGATIONS ARE
BARRACADING THE DOORS
b) TAMPERINGWITH OXYGEN SUPPLY
c) OVER WRAPPING THE CHILD
d) OVERUSE OF GYCERINE SUPPOSSITORIES
BARRACADING OF THE DOOR
Mr L Rogers Justice of the Peace. We observe his
notes as the only records of the hearing held at 2300 on 20th October 2000 (C18- 22)
Mr Rodgers states
“ Mrs Chaudhari has barricaded herself into
the hospital room where Sunaina is being treated and has placed objects over the door so she may alerted to nursing staff
and doctors upon entering. These were 19/10/00 at 2am and 5.20 am and 8.45am. Also 20/10/2000 at 11am.
Ms Maria Murphy states C26
“ Barricaded herself in the room preventing
access by the medical staff”
81. It is listed that Mrs Chaudhari had asked the
nursing staff to alert her when they entered so she may observe their attendance to the child. The nursing staff refused this
82. Due to the refusal it is established that Mrs
Chaudhari concerned for her child placed a spoon to balance on the door handle so that she could be alerted e.g. like an alarm.
83. “Everytime I have left the room Mrs Chaudhari
has barricaded the room with a chair and cutlery placed on top which clangs and falls each time I open the door.” D1315
84. It seems illogical that Mrs Chaudhari should
prevent anyone from entering the room where her child was being cared for. This
has not been documented in any previous admissions and indeed Mrs Chaudhari has never actually PREVENTED anyone entering the
room even on this occasion.
85. The facts are that individuals made entries
in the records on the above times and also were able to carry out their tasks. They had seen the child and Mrs Chaudhari had
not objected to their entry.
“Mum was standing up as if waiting for us
to go in. Sunaina was sleeping and very settled. Sat 99% in CPAP 6cm.”
At 0520 19/10/00 D315 Julie Stokes was indeed allowed
to enter and perform her duties and observations.”
* The implication in Mr Rogers’ notes is
that the mother barricaded herself in her room preventing care being given to her child.
* If this was indeed so, how did the nurse enter
the room, see the child asleep and was able to take the saturation’s without any criticism from Mrs Chaudhari?
The nursing staffs were never actually prevented from doing their duties.
As there were numerous entries in the records suggesting
clinical observations actually had taken place for the patient, this elucidates that nursing staffs were indeed allowed to
care for and attend to the patient. At no time was this prevented.
chair is a very lightweight plastic stacking chair and the spoon was used not to barricade the door to prevent entry BUT AS
We conclude therefore that Mrs Chaudhari’s motive was to use this method as an alarm, not for blocking purposes
or for prevention of treatment.
NB we were not allowed a picture by the offending
chair used by the Trust concerned.
This method of alert was clearly portrayed to be “alien” to the magistrate and assumed to be “mother’s
paranoia” by the staff.
A reasonable patient or parent who places objects behind doors to alert them to anyone entering the rooms may be because
* They want privacy
* They have a fear of unknown persons entering
a room when asleep
may well be in a state of undress at night!
These would be the actions of the “ reasonable
person “ and should not impute “ incompetence or a psychiatric condition”
It should be noted that for ones protection – this is the only practical way of knowing someone has entered the
room as there is no alarm or locks on hospital doors. A hospital room lacks privacy for this very reason and it is both difficult
for parents and patients alike to obtain this at long periods of stay.
We therefore consider this a reasonable method
for an alert. This may be unusual to the staff but nevertheless logical.
In conclusion, the chair and spoon were used as an alarm not a barricade given that no-one had actually been prevented
from entering the room and there was a clear record of observations during this period by nursing staff.
C26 is therefore misleading and factually inaccurate.
Ormond Street Hospital wish to make an assessment on Monday as to the immediate needs of the child’s future. Evidence
has been presented that parents and aunt are obstructing treatment and preventing staff from carrying out their care……
we therefore believe the only way to enable the assessment of Great Ormond Street on Monday is to make an EPO.
94. The above is illogical. It was at Mrs Chaudhari’s
request to the Chief Executive that Great Ormond Street’s opinion was sought.
If this is so, it seems strange that the Justice would assume that Mr and Mrs Chaudhari would obstruct Great Ormond
Street given it was her idea initially.
95. C21 “ And they do not accept the serious
nature of Sunaina’s illness and the prognosis is she will not survive. As a result it is felt that they will obstruct
any further attendance, observations and treatment of their daughter.
Mrs Chaudhari wished for a second opinion at all
As evidenced above she has not “ obstructed
attendance, observations and treatment of her daughter and therefore it would be illogical to assume this would be so in the
Comment: WE CONCLUDE THAT THE INFORMATION PROVIDED TO OBTAIN
THE EPO WAS MISLEADING AND THUS MISCONSTRUED WHEN ACCEPTED FOR APPLICATION
TAMPERING WITH OXYGEN SUPPLY
Throughout the medical records we observe that
there are various assumptions and misleading statements made regarding the use of oxygen and it effects.
There are two forms of allegations
* Tampering with actual Oxygen supply and consequences
of oxygen administration
* Use of CPAP
Firstly, we would like to clarify the scientific
basis and reliability of the medical advice stated in the meetings and correspondence.
In the meeting 10.10.00 the Consultant Dr Shirsalker made the following statement: -
“ If the oxygen supply is too high, the mechanisms
to fight infections can be damaged” C34 By Dr Shirsalker
We would like to question this entire statement (point 98) which is both misleading and incorrect.
In the literature we observe that from scientific evidence, high oxygen levels ACTUALLY IMPROVE THE MECHANISMS TO FIGHT
Mechanisms involved in fighting infections are cellular components. Oxygen
improves the ability of the cell to combat infections. This is clearly demonstrated in many scientific papers. In addition,
common logic will lead us to infer that insufficient oxygen supply to cells results in the death of cells whereas increased
oxygen increased the efficiency of cellular components such as neutrophils.
Sessler, D.I., et al. Supplemental perioperative
oxygen to reduce the incidence of surgical-wound infection. Outcomes Research Group. New England Journal of Medicine 2000
Jan 20;342(3):161-167. [ Abstract]
BACKGROUND: Destruction by oxidation, or oxidative
killing, is the most important defence against surgical pathogens and depends on the partial pressure of oxygen in contaminated
tissue. An easy method of improving oxygen tension in adequately perfused tissue is to increase the concentration of inspired
oxygen. We therefore tested the hypothesis that the supplemental administration of oxygen during the perioperative period
decreases the incidence of wound infection. METHODS: We randomly assigned 500 patients undergoing colorectal resection to
receive 30 percent or 80 percent inspired oxygen during the operation and for two hours afterward. Anaesthetic treatment was
standardised, and all patients received prophylactic antibiotic therapy. With use of a double-blind protocol, wounds were
evaluated daily until the patient was discharged and then at a clinic visit two weeks after surgery. We considered wounds
with culture-positive pus to be infected. The timing of suture removal and the date of discharge were determined by the surgeon,
who did not know the patient's treatment-group assignment. RESULTS: Arterial oxygen saturation was normal in both groups;
however, the arterial and subcutaneous partial pressure of oxygen was significantly higher in the patients given 80 percent
oxygen than in those given 30 percent oxygen. Among the 250 patients who received 80 percent oxygen, 13 (5.2 percent; 95 percent
confidence interval, 2.4 to 8.0 percent) had surgical-wound infections, as compared with 28 of the 250 patients given 30 percent
oxygen (11.2 percent; 95 percent confidence interval, 7.3 to 15.1 percent; P=0.01). The absolute difference between groups
was 6.0 percent (95 percent confidence interval, 1.2 to 10.8 percent). The duration of hospitalisation was similar in the
two groups. CONCLUSIONS: The perioperative administration of supplemental oxygen is a practical method of reducing the incidence
of surgical-wound infections.
We are able to provide other scientific papers
to contradict his stated opinion.
100. Comment: We conclude that
a) The information was inaccurate leading to assumptions
and also defamatory remarks about the mother.
b) The parent’s actions were actually beneficial
to the patient, contrary to liability portrayed.
c) The evidence above shows Dr Shirsalker to be
negligent in providing information. This has led to assumptions being made for the Emergency Protection Order and at meetings
d) We would like to therefore question the accuracy
of his other statements.
second statement is made in the letter dated 22.10.00 GO33 from Dr Petros to Caroline Harrison
He states “ High concentration of oxygen
via nasal cannulae can cause pulmonary fibrosis or lung damage. Unnecessary oxygen enriched air for long periods may also
cause similar changes “
scientific facts are
The amount of oxygen supplied through nasal cannulae is restricted by flow.
maximum amount through nasal cannulae is approximately 2 litres (which is equivalent to 30-40% FiO2). Dr Petros may be referring
to hyperbaric oxygen levels (100% FiO2 ie at least 8Litres flow) which were not used here.
ii) There are no clinical studies or animal studies
to suggest that oxygen given by nasal cannulae causes lung damage. Thus, nasal
cannulae oxygen does not cause pulmonary fibrosis nor does it constitute “high concentrations of oxygen”
iii) Tests with hyperbaric oxygen are known in
animals but nasal cannulae cannot supply this amount of oxygen .
statement (point 101) to support the EPO is therefore factually and scientifically inaccurate and intentionally misleading
to the parents and legal personnel court.
104.Comment: WE CONCLUDE THAT GIVEN THESE INACCURATE
FACTS PRESENTED TO THE SOCIAL SERVICES TEAM, THE INCIDENTS STIPULATED BY THE MEDICAL/NURSING
STAFF DO NOT CONSTITUTE “ SIGNIFICANT HARM “.
Thus, the medical information contained in these
letters were intentionally misleading and false when seeking an EPO.
SUPPLY AND INCIDENTS
There were many incidents noted regarding the oxygen
supply. In our opinion we do not feel they are significant, as they could have a simple or accidental explanation. Nevertheless
to clarify matters we have endeavoured to stipulate the directives that operate in each situation.
106. INCIDENT 1 and 2 and 3
15.8.00 Clover ward
16.8.00 Redbridge Children’s Centre
Oxygen was apparently turned up at home during
incidents (106, 1&2) occurred at health centres. The parent received the blame on such occasions for “holding an
inadequate supply of oxygen”. It is said in the court papers that her husband had the spare oxygen cylinder in his car.
have a few comments to make on these two incidents
1) The circumstances were accidental and not intentional
2) There is no motive that the mother intended
to harm her child
3) Finally, all NHS directives stipulate that once
the patient has presented themselves for medical care, the responsibility of the health institution exists to ensure that appropriate medical care of the child is given
at the time of entry to that building.
4) We would therefore stipulate that Redbridge
Child Care Centre should have a supply of oxygen if they are treating patients that require this. Clover ward had an adequate
oxygen supply although still placed the blame on the parent.
5) Any clinical incident occurring on NHS premises
is the responsibility of that NHS institution.
6) We therefore suggest that facilities may have
been inadequate at these centres.
7) No inferences therefore can therefore be made
from these two incidents regarding ‘significant harm’ due to the above.
3 Contradictory evidence
KW30 states in a multidisciplinary meeting that
“ Explained that at on arrival at EVERY visit
the oxygen has been turned up to 0.4 L when at the previous visit it is turned down to 0.2L”
In actual fact despite this statement in the minutes
of the meeting where she took great pains to degrade the care provided by Mrs Chaudhari , we note that “EVERY”
is an inaccurate word. On perusal of her own records of the care provided (HC10) we note that throughout her visits there
was only one occasion where she found the oxygen turned up.
HC10 7/8/00 “ In 0.4L O2 on arrival, dad
said he had forgotten to switch down following suction. Explained that rate does not need increasing unless Sunaina is experiencing
difficulty breathing. Turned down to 0.2 L. Father only present “ Signed Michele Riceman.
110. Comment: It is common knowledge that increasing the Oxygen to 0.4 L does no harm to the child.
It was perfectly feasible to have had it turned up following suction or other activity.
This incident (109) was accidental and irrelevant.
It bears no relevance towards facts of incompetence.
CONCLUSION, ON THE BALANCE OF PROBABILITIES THESE INCIDENTS to do with oxygen WERE NOT SIGNIFICANT AT ALL.
There have been many recorded incidents regarding
the CPAP machine. When considering this we should take the training Mrs Chaudhari
had since her child’s birth. Mrs Chaudhari was responsible for Sunaina’s
care 24 hours a day. In addition she was taught by staff at Special Care Baby Unit on how to work the CPAP machine. Once the
CPAP machine is set up, the procedure of checking saturation’s and the day to day workings is very simple and would
not cause any harm. During her time with Special Baby Care she was allowed to
control the CPAP machine.
took the liberty of testing Ms Chaudhari’s knowledge of the CPAP machine
ACCOUNT WRITTEN WITHOUT ASSISTANCE (this can be examined at a later time on questioning)
“The oxygen supply for the CPAP machine came
directly from the wall with acircular socket. The wide circumferenced tubing attached to the CPAP machine which allows oxygen
through is inserted into the circular wall socket by pushing into it and then by turning it so that
it locks. The humidifier barrel is slid into place
and topped up to the
marked level with sterilised water .The tubings
are connected from the
humidifier and from the face of the CPAP machine
to the nose piece. The nose piece is attached to the patient via two elasticated attachments which are threaded through holes
in the special CPAP cap worn by the patient. By adjusting the elasticated attachments to the correct position and tension
the nose piece can be fitted into place on the patient.The electrical plugs from the CPAP machine are plugged in so that the
readings on the face of the machine are seen and the temperature of the humidifier can be seen. The temperature of the humidifier
is set between 36- 37 Ci.e body temperature. Once the temperature of the humidifier has been reached and stabalised the CPAP
machine is ready to be connected to the patient. There
is a special plug fitted on top of the humidifier,
which can be used to top up the level of water in the humidifier, which decreases, with time of use
. The oxygen from the wall supply passes through
the humidifier reaches body temperature before entering the patient. The pressure gauge on the face of the CPAP machine needs
to be maintained in the correct range shown by green/yellow light. If the range is within the red light then the pressure
needs to be checked, either by checking the nosepiece or by adjusting the pressure control to the correct range. The oxygen
control is adjusted so that saturation (Sats) are maintained between 98- 100%. I was left to control the CPAP machine when
Snaina was in SCBU-Special Care Baby Unit, and during the
last admission from 1-10-00. I hope that I have
July 18 2000
See D158 for preliminary discussions about discharge,
reference to 'Infant
flow driver, by observing nurses she has learnt
to use it'
See D159 'Assess what Mrs C has learnt about Infant
flow driver and begin to
provide further teaching identified'
See 136 “ Agreed to change nasal prongs and
O2 cylinder for practice” (24/6/00)
See “ Orogastric tube and nasal prong changed
this afternoon, mum changed the O2 cylinder for practice"”(24/6/00)
mother in oral suctioning and inserting nasal cannulae. Satisfactory in both”
(20.20, 25/6/00 (Sandford)
STAFF INVOLVED IN TRAINING MRS CHAUDHARI
* Vera – Mrs Chaudhari told Vera that she
already knew how to fit the cap and nosepiece but asked how to connect the tubes. Vera said it was easy and spent 5-10 minutes
* Eileen Regan - Night nurse- Mrs Chaurdhuri watched
how she put on CPAP and took it off on many occasions
* Diane - main person who showed Dolly how to work
the CPAP machine
* Barbara - Showed Dolly how to adjust the controls
to bring the sats up
We are satisfied from the above that Mrs Chaudhari
was able to use the CPAP machine adequately and had been trained by the Special Care Baby Unit staff to do so. This is also evidenced by the fact that throughout the records there are no incidents documented (nor critical
incident risk forms) where her child came to any harm whilst this was used by her.
is established fact that Mrs Chaurdhuri spent 24 hours caring for her baby. She is an intelligent and able lady who was able
to work the CPAP machine adequately.
Throughout the records, the aim was to wean the child off CPAP therefore it was not unusual for Mrs Chaudhari to intermittently
take Sunaina off the CPAP machine, as she was experienced in this from her last admission.
CPAP is also beneficial to the child and accepted in practice to prevent nasal excoriation.
“ Delivering mechanical ventilation in the form of continuous positive ventilation. Albeit a gentle form of ventilation
could be potentially lethal in untrained hands if a mechanical errors occurs. CPAP should certainly not be applied by anyone
other than medically authorised personnel “ by Dr Petros Great Ormond Street”
There were never any mechanical errors over the two months that Mrs Chaudhari was allowed to use the machine and therefore
the probability that this would occur is identical to the medical staff.
ii) The comment is thus misleading given that Mrs
Chaudhari had been allowed to use the CPAP machine on many occasions. Infact
Dr Robinson in his meeting on 10/10/00 stated that “an option would be to discharge the child on CPAP”.
119. Comment: We thus consider this generalised statement by Dr Petros to
be inappropriate for this case. The opinion relayed in such a statement provides
an inaccurate emphasis as it is based on assumptions with no due regard to the training Mrs Chaudhari already had.
OVERWRAPPING THE CHILD
See chronology page 5 of 12th Sept – Mother
refuses to accept that she was over wrapping Sunaina. After an incident when
Sunaina went all cold, mother ensured this did not happen again
have not seen any communications between the staff explaining in detail the logic behind removing clothes. It should be noted
that this failure in communication has resulted in numerous accusations of incompetence alleged. These are false accusations
as a) no documented temperature to prove hyperpyrexia and b) wrapping this child in clothes did not produce significant harm
and c) therefore should not be considered as such without positive evidence.
FREQUENT INSERTION OF FRAGMENTS OF GLYCRINE SUPPOSITORIES
The statement written by Dr A Petros states (GO33)
“ Finally we were informed because of the
family’s holistic/homeopathic beliefs Sunaina was having fragments of glycerine suppositories inserted into her rectum
every four hours”
“ Repeated and frequent unnecessary insertion
of rectal suppositories can lead to anal canal tears and subsequent infections which could be ultimately life threatening
statements are disputed as
a) There is no documentary evidence that this ever
occurred (in any clinical notes)
b) There were never any such infections, in any
event this is extremely rare in paediatric practice, with no such clinical reports in the medical literature
c) If glycerine suppositories were used, they would
need to be prescribed due to clinical need
d) While in hospital, all medications are usually
supplied to patients by nursing and medical staff.
In conclusion, we find the basis of Emergency Protection Order was factually inaccurate and medically ill advised.
The initiation of this order was based on issues unrelated to the care or competence of parents. The parents did not
pose any significant harm to the patient; rather they became an irritation to the staff.
Deteriorating staff patience, irritation and dissolving communications promoted the use of an EPO to obtain a way for
staff to exclude parents from the ward and their child.
The Emergency Order taken out on the basis of the information supplied here was fraudulent.
EPOs is used in cases of abuse and neglect where there is a risk of significant harm to the patient.
The Paediatric staff of King George and Intensivists at GOS have abused the use of the Emergency Protection Order.
The Chief Executive failed to take appropriate action when these disputes were brought to his knowledge by way of a
letter of complaint in 5th October 2000 from Mrs Chaudhari (section 4).
The disagreements could have been resolved through a
different avenue eg by transferring to another hospital, which could provide equal paediatric facilities, and an impartial
nursing and paediatric team who could facilitate communications. This would have
been acceptable to both parents and staff.
Further, the Paediatric team intended to allow
the child to die and consideration must be made as to whether this EPO was manoeuvred for a “do not resuscitate”
PESONALITY CONFLICTS, COMMUNICATIONS FAILURES
and Trust are the main components of good patient- doctor relationships. This is stated in many directives in the BMA and
GMC. Failure of these two most important entities leads to direct conflicts and
mistrust of both parties.
the beginning of the child’s birth, it is noted that doctors have been very negative regarding the prognosis of the
child. In addition, this has caused the initial mistrust within the doctor-patient relationship, which is understandable in
any “ reasonable person”.
frustration of the parents with the medical professionals was compounded further by the non provision of an interpreter for
Mr Chaudhari who felt “ shut out” of his own child’s care (interpreter was only offered after her letter
of complaint in October 2000). This naturally has caused resentment. No professional has taken the time to explain the issues
to the parents to regain their trust.
this report we have illustrated confidentiality problems, misconceptions of events by the staff, inaccurate details in the
Emergency protection order and a severe lack of explanation to a mother who is understandably overwhelmed by the responsibility
of caring for a child who has a disability compounded by doctors insisting that her child will die.
130. Mrs Chaudhari has done her best for her child.
On the 5th October 2000 she wrote her initial letter of complaint to the Chief Executive.
Following this matters escalated where nursing staff misconstrued any small action by her, intentionally or not.
131. Mrs Chaudhari’s concerns were
* Harassment and Victimisation by staff
* Inadequate care
* She stated she was tired and required urgent
She stated Letter to Mr Peter Murphy A24 from Ms
“ I have been providing 24 hour care for
my baby and have been subjected to harassment by senior managers “
note that the escalation of the complaints by the nursing staff increased after the letter dated 5th October 2000, suggesting
victimization. Her concerns were not allayed. There were numerous disagreements
* who should control the CPAP machine/ Oxygen
* Only medical professionals should do the suctioning
* Saturations monitored inadequately
* The complaints from Mrs Chaudhari was that the
ward was short staffed
* Senior managers would come to her unannounced
* Symptoms of irritation were shown in the nursing
staff’s records. They became oversensitive to disconnections of CPAP (when Mrs Chaudhari had been trained to do this
in SCBU). No harm had come to the baby.
* Irritation of the nursing staff when Mrs Chaudhari
the weeks following the letter of complaint, it is clearly noted that the entries by nurses is specifically directed against
Mrs Chaudhari, as opposed to comments on the care of the child. These notes consisted
entirely of personality conflicts as opposed to clinical content.
Decisions were made without consulting or explaining situations to her and her husband.
2/10/00-Dr Shrisalker stopped all treatment without
discussion with parents. This caused further conflicts. Normal practice would be that each drug would be removed as a staged
process e.g. over a few days or weeks to provide a more controlled management of the child.
Step 1 Stop antibiotics
Step 2 Stop frusemide/spironolactone
Step 3 Trial off CPAP
All these steps were done together and this resulted
a) Conflicts between staff and parents
b) Deterioration in the patient
a clinician is posed with this problem, they have a duty of care to terminate the relationship between the patient and themselves
and ensure care is provided where there is objective approach with mutual trust and confidence.
135. Irrelevant remarks were made in the medical
records, which were done at the previous admission
Mrs Choudry clicked her finger to Beatrice and
saying baby needs suction now. This was said as she went on her way to answer the phone when Mrs Choudry came off the phone
I spoke to her and requested that Beatrice shows her how to suction baby so that she can attend to her needs herself instead
of clicking her fingers at nurses. Mrs Choudry is happy to undertake this task” D38 (name illegible)
few salient feature are noted from this statement
a) It is logical that a person should click their
fingers to gain the attention of the nursing staff, as they were obviously busy. Mrs
Chaudhari merely tried to get their attention
b) Clicking fingers is a cultural method of getting
the attention of someone, which is very common with Asians.
c) “ The sentence she can attend to her needs
herself “ implies to any reasonable person that the nursing staff
i) Did not wish to be disturbed and were clearly
irritated by the “ clicking of fingers “
ii) Instructed the mother in order to avoid the
tasks that they should have been carrying out.
iii) Suctioning is a nursing task, which was left
for the parent to carry out.
iv) Please note the misspelling of Mrs Chaudhari’s
name on many occasions showing a lack of care for cultural names. No allowance was given to the different behaviours in cultural terms
Guidelines Good Medical Practice
Professional relationships with patients
1.2 Successful relationships between doctors and
patients depend on trust. To establish and maintain that trusts you must:
* Listen to patients and respect their views
* Treat patients politely and considerately
* Respect patients’ privacy and dignity
* Give patients the information they ask for or
need about their condition, its treatment and prognosis. You should provide this information to those with parental responsibility
where patients are under 16 years old and lack the maturity to understand what their condition or its treatment may involve,
provided you judge it to be in the child’s best interests to do so.
* Give information to patients in a way they can
* Be satisfied that , wherever possible , the patient
has understood what is proposed, and consents to it, before you provide treatment or investigate a patient’s condition
* Respect the right of patients to be fully involved
in decisions about their care
* Respect the right of parents to decline treatment
or decline to take part in teaching or research
* Respect the right of patients to a second opinion
* Be readily accessible to patients and colleagues
when you are on duty
You must do your best to establish and maintain a relationship of trust with your patients. Rarely, there may be circumstances
in which you find it necessary to end a professional relationship with a patient. You must be satisfied your decision is fair
and does not contravene the guidance in para 13; you must be prepared to justify your decision if called to do so. In such
cases you should usually tell the patient why you have made this decision. You must also take steps to ensure that arrangements
are made quickly for the continuing care of the patient. You should hand over records or other information to the patient’s
new doctor as soon as possible.
AT THIS POINT THERE WAS A SEVERE RELATIONSHIP BREAKDOWN
COMPOUNDED BY THE OVER SENSITIVITY OF THE STAFF TO EVERY ACTION THAT WAS TAKEN BY THE PARENTS.
MATTER ESCALATED TO INCLUDE
a) Misleading and inaccurate information
b) There was no independent management initiative
to solve the problem
c) We therefore observe the scenario seen commonly
between health professionals and patients when a relationship deteriorates.
d) Personal anger and irritation of the nursing
staff thus resulted in misconstrued information
e) We cannot comment on their motive for this.
f) We then observe the domino effects of “hearsay”
where the situation becomes entirely uncontrollable.
REQUEST TO TRANSFER THE CHILD WAS DENIED
16th October 2000 (D8) Letter to Liz Pointing (Nursing
Directorate) from Great Ormond Street (Andrew Hines)
Dr Colin Wallis, Consultant Paediatric Respiratory
Medicine has agreed to take over the management of Suneena at Great Ormond Street.
16th October 2000
D7 Letter from Great Ormond Street (Mark Peters)
to Dr Robinson – 18th October 2000 “ I explained that there is no
suitable bed for this infant on the Intensive Care Unit at Great Ormond Street “
This would imply to the reasonable person that
there was no bed available.
A20 Letter to Linda Perham 11th October 2000
“ The hospital arranged for Social Services
to visit me unannounced at 6.15 yesterday. The latter accused me of getting in the way of nurses and doctors and threatened
to take legal action against me “
D7 Letter from Mark Peters 18th October 2000
“As explained at present there is no suitable
bed for this infant on the Intensive care Unit at Great Ormond Street
to the gravity of the situation and immediate requirement of transfer, the most logical course of action would have been to
transfer the baby to another hospital.
Each letter from parents requests for Sunaina to
be transferred to another hospital for supportive care at an equal intensity and where there might have been an improved relationship
between staff and parents. These requests were ignored.
CHILD WAS NOT TRANSFERRED DESPITE THE REQUIREMENT UNDER THE PATIENTS CHARTER THAT THEY CAN OBTAIN A SECOND OPINION.
144. Great Ormond Street was called for a second
opinion instead on the 20/10/00 who advised the Emergency Protection Order, Judicial Review etc. There was no communication
of this UNILATERAL change of plan.
In essence, the EPO was used to obtain a DNR order by covert methods.
CONCLUSION we state that misleading the parents and performing unilateral decisions contrary to their wishes is a breach of
their fundamental rights stipulated by the Patients Charter and numerous directives.
Always feel that you can ask for information or
advice as many questions and as often as you need. Ask the people you trust and who can give you the information you need."
Dr Una MacFadyen: Consultant Paediatrician.
OF A PSYCHIATRIC CONDITION WITH RESPECT TO MS SADHANA CHAUDHARI.
Throughout the records, we have noted the inference
of various staff who have questioned Mrs Chaudhari’s psychological wellbeing.
It must be stressed that to be “ upset” does NOT mean that one is psychiatrically ill.
We have read the correspondence from Ms Chaudhari
to Mr Peter Murphy (Chief Executive of the Trust) and clearly this is a lady who was concerned for the welfare of her child.
She was exhausted at caring for her child as she felt due to her past experience she could not trust the staff.
Her initial complaint to the Trust was on 5th October
2000 (A 24) which states her concerns regarding the
a) Attitude of the staff
b) Victimisation by staff
In this letter she details her concerns regarding
the lack of care provided.
We note that instead of dealing with these concerns,
on this very day 5th October 2000 curiously she was referred to a Psychotherapist (G14)
by “ Ann Mahoney, Dr Shrilasker and Sr Angela “. (Seen by Denise
Cahill). We note that no referral was made to a psychiatrist at this point in time. Clearly there was no clinical need.
147. PAST EPISODES
Pam Hanton Health Visitor
Meeting minutes 5/9/00
“ Main concern is mother herself- displays
unusual behaviour – very volatile. Still registered with GP in Sidcup. Practice describes behaviour as normal for her. No previous mental health problems. Sometimes wears florid coloured clothes and is
From this we infer that
a) Ms Hanton has no idea or concept of Indian clothing
which are naturally florid in colour and is of no reflection on a person’s psyche.
b) By these remarks Ms Hanton is insinuating that
Ms Chaudhari may be a manic-depressive or other serious psychiatric illness.
We find Mrs Hanton’s subjective judgement to be based on her
Caucasian outlook on life.
In addition, Ms Chaudhari has no mental health problems; there has been no psychiatric
report on her. There has been no requirement for this and therefore we can conclude
that in the absence of this evidence, these remarks are defamatory.
would hope that their legal advisors would consider an action for defamation due to these remarks that have labelled her throughout
her time at King Georges. This has caused antagonism between herself and staff, which is understandable. Without psychiatric evidence at the time, any questions of her mental health must be dispersed. We therefore
state that subjective judgement and gossip by staff is not a diagnosis for a mental illness, which this lady seems to be labelled
our opinion, we feel that Ms Sadhana is an able and caring mother. In addition, given the rough terrain of her environment
her reaction was not abnormal. Any reasonable mother would have reacted in the
same way. To be UNHAPPY or UPSET is not a mental illness and should never be
construed as such.
- meeting 10th October, minutes on 19th October
From the information provided, there is no indication that Mrs Chaudhari is suffering from permanent psychotic features. There
are no clear reasons to considering sectioning Mrs Chaudhari at the current time “
Comment – Mr Paul Hemmingway should not have
been party to confidential information regarding the mother. The correct method
of dealing with these concerns would have been to
Approach her family with concerns
ii) Perhaps inform her own General Practitioner
information regarding Mr and Mrs Chaudhari or the child should have been provided to this individual without the express consent
of the family.
iv) Mr Hemingway was clearly asked to attend in
order to consider “ sectioning Mrs Chaudhari “ which is an imputation of mental illness. This is therefore a breach
of confidentiality and further evidence of possible defamation.
Given that there is no past history of mental health
problems, there is no psychiatrist report and there is no evidence of mental health symptoms we conclude that Ms Sandhana
was victimised and harassed by the staff of King George’s possibly due to her complaint.
This is shown by the action of referral to a psychotherapist on the same day that her complaint was written to the
Chief Executive. This form of behaviour demonstrates to us that for some reason unknown, Mrs Chaudhari’s remarks and
complaints were threatening to the staff and hence to decrease her credibility regarding the complaints – the psychotherapist
was called expressly implying that she is not in “ her right “ mind.
This is the only plausible explanation of referral to a psychotherapist on the same day as the complaint was made.
CONFIDENTIALITY AND CONSENT ISSUES
Confidentiality and Consent issues are paramount in medical practice.
We have had grave concerns regarding these issues throughout the medical records.
We have taken the liberty of providing the Department of Health guidelines on this subject (appendix 3) The British
Medical Association and General Medical Council guidelines are identical.
There are no documents during the Emergency Protection
Order stipulating that the King George’s Hospital was implicitly instructed to carry out any treatment they wished.
The Emergency protection order itself does not
state any issues about consent
these circumstances and the fact there is an absence of a court order making the child a ward of the court leads us to the
conclusion that the consent remained with the parents and at no time were the parents consulted regarding the treatment after
the 20th October 2000
We infer from the numerous documents requesting
the transfer of their child to another hospital that they DID NOT have the authority to treat the child.
infliction of the child without the consent of the parents is an infringement of the child’s rights and in addition
known as battery/ assault.
We note from Mr and Mrs Chaudhari’s statements
to us that at no time did they consent to treatment of their daughter. Their legal advisors will no doubt be the best people
to investigate this matter.
Gillian Strawford, a medico-legal adviser at The MDU says:
Obtaining patient consent is integral to the doctor/patient
relationship. Knowing when and in what circumstances a minor can consent to their own treatment is important for all doctors.
A doctor who has taken reasonable care in the course of treatment, and is not vulnerable to an allegation of negligence, could
still be pursued under the civil and criminal law for assault on the grounds that valid consent was not obtained.?
Throughout the case records there is no
* Documentation stating the issue of consent had
* There are no meetings where this was mentioned
* The family were not told or asked their consent
* There are no signed documents relating to consent
156. Comment: In our opinion given the status of the Emergency protection Order, it was highly
negligent of the medical professionals and their legal advisors not to discuss the issue of consent. We cannot infer from
the above that there was any implied or express consent that was obtained
You may release confidential information in strict
accordance with the patient’s consent, or the consent of a person properly authorised to act on the patient’s
of Potential breach of confidentiality
MEETING MINUTES HELD ON 10. 10.00 although it was
curiously dated 19.10.00 under the name Maria Murphy. This was the day before
the application for court and we can conclude it was typed up for that purpose.
It must be noted that this meeting took place without
the parents therefore any individuals who were not part of the immediate care were introduced without the consent of the parents.
a) It should be noted that vital personal healthcare
information about the child and mother were disclosed at this meeting.
b) The individuals we identify who were asked to
attend the meeting and who were not involved in the direct care of Sunaina Chaudhari were
1) Paul Hemmingway – who was not directly
involved in the child’s care
2) Phyllis Abraham
3) Denise Martin
4) Teresa Walsh Jones
5) Maria Murphy
22nd August 2000
number of officials have been listed. We note that the person Ileen Ashitey Child
Protection Specialist has never been part of the original team.
a) We have seen no recordings made by her
b) The family have never met her
c) The family have not consented to her being party
to this meeting
d) We therefore state that to disclose information
to this individual without first speaking to the family constitutes a breach of confidentiality
conclude therefore that any information disclosed to these individuals without the prior knowledge or agreement of the parents
constitute a breach of confidentiality. These issues will be required to be investigated by the legal advisors.
This is a letter dated the 25th October 2000 from Dr A Petros of Great Ormond Street to Caroline Harrison, Solicitor of King
Georges Hospital Redbridge
Great Ormond Street is an independent Trust and
Dr Petros possessed the data for Redbridge Trust patient. This information was disclosed to a solicitor without the express
consent of the family.
Dr Petros works is an independent Trust and was
asked to provide an independent opinion of the patient for appropriateness of intensive care.
It should be noted that at no time did Dr Petros
speak to the family
At no time was the consent of the parents sought
to examine the child
All decisions made were unilateral based on a skewed
perception of the clinical situation and disregarding any opinion from parents
At no time did he obtain the consent of the family
to disclose matters pertaining to the family to a third party namely the solicitor at the Trust, a person who was not directly
responsible for the care of the patient
The Emergency Protection Order does not waiver
the requirement of consent or confidentiality for disclosure of medical details.
We observe that medical details of the patient
has been disclosed without the consent of the parents.
We note that his own colleague Dr Goldman who is
consultant in palliative care medicine advocates the following
“”Every child and family is unique
and bring their own beliefs, culture, coping skills and communication style when they are facing these difficult and terrible
situations. Our task is to try to work with them to try to find a way forward that is firstly in the best interest of the
received in an email to us dated 7th June 2001)
Consultant in Palliative Care
Great Ormond Street Hospital
Great Ormond Street
London WC1N 3JH
phone 0207 829 8678
fax 0207 813 8588
THIS PATIENT DYING?
All decisions in the case of this patient has been
governed by the assumption that she was dying and no further intervention would be of benefit to her.
a) It should be noted that despite the assumptions
that she would die
ii) At birth
iii) After the diaphragmatic hernia operation
These predictions were proven wrong.
leads us to conclude (and should have led the same clinicians to conclude) that this child did have the capacity to maintain
life and was stronger than their medical opinion assumed. Logically, the probability of death would have been at its maximum
ie highest expected mortality, at the time of the surgical intervention. Risks
of surgery and post-operative death is additive as extra stress occurs to the infant.
surgical intervention did not cause the death of the individual. In fact on 31st
July 2000 she was well enough to return home with her parents.
Throughout the medical records and expert witness reports we note that there are many assumptions made as to the cause
of death. We would like to provide an outline of each condition, which this patient
had and consider the potential likelihood of death.
13th October 2000 Letter from Dr Shirsalkar to
Professor Dinwiddy stated (D10)
1) Trisomy 18 Edwards Syndrome
2) Repair diaphragmatic hernia at GOS on the 7th
day of life
3) Chronic lung disease oxygen dependent
4) Small VSD , clinically closed
5) Posterial fossa cyst on CT scan
6) Bilateral hearing loss
7) Perinatal gastric perforation operated upon at the same time as diaphragmatic hernia
8) Group B Strep septicaemia in the neonatal period
will now consider each condition in turn to assess if the direct cause of death can be attributable to one or more medical
Trisomy 18 discussion as above. This is not a disease
or an illness – it is a condition that affects each individual differently, with a spectrum of associated congenital
conditions of other organs.
Left Congenital Diaphragmatic Hernia
From We 4 and Professor Weindling Page 3
“ Congenital Diaphragmatic Hernia (CDH) is
also a very serious condition, associated with significant mortality and morbidity. The incidence of congenital diaphragmatic
hernia is 1 per 2-4000 births. It is a developmental abnormality and is due to a failure of the diaphragm to close correctly.
Surgical repair is usually fairly straightforward and the serious clinical consequences of this condition are due to a failure
of development of the lung and its blood supply on the side of the hernia. The earlier the diagnosis is made (as in this case),
the more likely there is to be significant impairment of lung growth. The small lung is called “ hypoplastic”
and the condition is known as pulmonary hypoplasia. As in Sunaina’s case, pulmonary hypertension is not uncommon complication
of this arrested pulmonary development”
a) Mr Pierro of Great Ormond Street 1.6.00 successfully
carried out the diaphragmatic repair
b) The complications listed are
* Gp B streptococcus ( Blood Cultures 25/5) which
was again successfully treated with Ampicillin and Amikacin Go18
* Large left pleural effusion which was successfully
drained ( GO17)
* She was discharged on the 8th June 2000 to be
followed up locally
* The discharge summary which shows that Sunaina
was in a fairly good state physically ( GO 23-25)
* Successful repair of a Congenital Diaphragmatic
Hernia increases the probability of survival.
Perinatol 2000 Dec;24(6):418-28
Congenital diaphragmatic hernia: where are we and
where do we go from here?
Muratore CS, Wilson JM.Department of Surgery, Children’s
Hospital and Harvard Medical School, Boston, MA 02115, USA.
“CDH survival is close to 90% at most advanced
( Great Ormond Street is classified as an advanced
d)There are complications of diaphragmatic hernias.
The most notable stipulated by Professor Weindling is pulmonary hypoplasia.
We would like to discuss the condition of pulmonary
hypoplasia and the extent to which this affected her.
THE PATIENT HAVE SIGNIFICANT PULMONARY HYPOPLASIA and PULMONARY HYPERTENSION ?
hypertension is caused by pulmonary vascular resistance secondary to various lung pathology. This could be
ANATOMICAL – i.e. actual physical size is
PHYSIOLOGICAL – problems lie in the actual
physiology of the lungs
HYPOPLASTIC LUNGS are lungs that are anatomically too small to sustain
life and would result in early death. This patient survived until 5 months.
171. She was oxygen dependent but only required
modest oxygen (30-40% FiO2) and thus did not have severe anatomical pulmonary hypoplasia.
172. She did have pulmonary hypertension; the degree
is difficult to accurately predict. The treatment for pulmonary hypertension is nitric oxide, vasodilators and oxygen. The
practical recommendation is to maintain high oxygen levels (98% saturation) which minimises the pulmonary hypertension and
reduces the risk of heart failure (cor pulmonale).
173. The patient did not have significant pulmonary
hypoplasia as she survived diaphragmatic repair (commonest cause of death is due to pulmonary hypoplasia).
174. This provides evidence against anatomical
reasons causing pulmonary hypoplasia.
175. We provide further evidence by the following
Professor Risdon’s Post-mortem report states
The bronchi were congested. The left lung weighed 40.7g and the right lung 33.9.
(Weight of child 4750g)
There is no mention of pulmonary hypoplasia in the PM report
Reference for lung weight suggest that this is not within the hypoplastic range
most probable cause of Pulmonary Hypertension is thus physiological in nature
* This is a reversible condition – TREATABLE
* Has a much better probability of survival
* Reversibility is with optimising oxygen
conclusion, Professor Weindling’s assumption of “ As in Sunaina’s case. Pulmonary hypertension is not a
uncommon complication of this arrested pulmonary development” is inaccurate as
* There is no scientific evidence for that the
lungs were indeed hypoplastic.
* The natural history of severe lung hypoplasia
is very early or immediate death at birth.
* Pulmonary hypertension is not in this case caused
by arrested development of the lungs – it is caused by physiological changes in the vasculature.
LUNG DISEASE - evidence that this did not cause sudden death
a) Professor Risdon’s Pathology report on
“ Normal nose and nasopharynx. Normal larynx.
The trachea contained a little food material. The bronchi were congested. The left lung weighed 40.7gm and the Right lung
33.9. The pleural surfaces of both lungs were pitted and fissured. On section the parenchyma was congested and a little white
material was expressed from small airways on their cut surfaces.
There is a focal thickening of alveolar septa and
many terminal airspaces are markedly dilated. There are also areas of collapse and most airspaces contain foamy, and some
iron laden macrophages. Pulmonary arteries and arterioles show changes associated with pulmonary hypertension.
We infer from the anatomical examination that
* Lung changes seen were consistent with inflammation
and pulmonary hypertension, or chronic lung disease
* This histology is not consistent with severe
or terminal lung disease
* There is no evidence of profound acute lung infection
(no bronchopneumonia) – consolidation or neutrophilia leading to sudden death
b) CLINICALLY during October 2000 admission
* All blood gases were within normal range of acid
status (normal blood pH 7.44 compensated). There were no documented uncompensated raised PCO2 levels throughout her stay at
King George’s Hospital.
* There was no progressive increase in oxygen requirements
(ie above 60% FiO2), this would be evident if lung disease was becoming worse
* Chest X-rays show good lung inflation in both
lungs (X-rays taken on 25/9/2000 and 14/10/2000 showed no difference in lung
* All blood culture results and Virology was negative
– no positive infection identified
Comparing her medical condition, we would infer
that the patient was no worse when she was discharged home on 25/9/00 than on 14/10/2000, six days before the Emergency Protection
Order was served.
The X-rays do not show any signs of infection nor
the classical changes of severe chronic lung disease.
Professor Risdon lists that all Microbiology was
negative eliminating infection as a cause of exacerbation of her lung disease.
We therefore conclude that although there was chronic
lung disease and pulmonary hypertension, these medical conditions were clinically treated and hence are not the cause of immediate
death on 26th October 2000.
It certainly should not be a reason for withdrawing
COMPLICATIONS – Small Ventricular Septal Defect was not clinically significant
There have been no worries from the cardiovascular point of view. The VSD is considered small… She has been reviewed
by a cardiologist and it is not thought that any intervention would be necessary.
D72 Cardiology Opinion
“ I have discussed with mum that the VSD
is not affecting the baby at this stage “
“This is now clinically closed ““
(summary dated 25th October 2000 by Dr Shirsalkar
“The heart sounds were normal” ( Dr Petros, 0515 25th
October 2000 Great Ormond Street
We therefore conclude that this heart anomaly alone would not have contributed
to immediate death. It was clinically closed and thus functioning as a normal
We thus state that this is not a contributing cause
of her death.
FOSSA CYST IN THE BRAIN
PM and CT Scan of her brain showed
Large cyst in the posterior fossa (back of the
brain) – cerebellar hypoplasia (= small or underdeveloped cerebellum)
a) This congenital lesion would not have directly
caused the death of this child
b) This abnormality causes neurodevelopmental delay
(morbidity) but is not a contributory factor in immediate death .
Although it is known that Trisomy 18 children are
prone to central apnoeas, there was no previous documented evidence that the patient had episodes suggesting this condition
by either the nursing or medical notes.
Usually, the pattern would be repeated episodes
of apnoea before a profound or solitary one leading to death
WEIGHT – its significance to well being
a) ” The capacity to grow and develop is
the essence of childhood “ (Oxford Textbook of Specialities p184)
gain is a prime indicator of progress of a child
c) A child who is dying would rarely gain weight
d) This child did not show any evidence of failing
e) This is plotted on Centile charts. The figures
at the end of each of the curves refer to centiles. If a child is growing along the third centile this means that only 3%
of children from a healthy normal population has a growth rate as low or lower than such a child.
f) It should be noted that not all-ethnic populations
are the same. While such a child can be said to be abnormally small if he is
a well fed Caucasian, this need by no means be the case if he is of Asian extraction.
g) Weight gain (this can be seen in Personal Child
Health Records) where the weight was seen to increase from 2.64 kg to 4.70kg. This is elucidated by increasing ( linear )
h) “On examination we found Sunaina well
below the 3rd centile for weight and length and is very much further below the 3rd centile for head circumference” (A26
Great Ormond Street).
There is no record by Great Ormond St of Sunaina’s
head circumference or growth
find enclosed a TABLE SHOWING THE INCREASE OF WEIGHT
Taken from Ch9
Wt ( kg)
Weight at death 4.740g
Professor Venezis (1/2/01) states PM report “ The body was that of a well nourished female infant “
infer from this table that this child was infact growing well while she was in the care of parents. She may have been below centiles but her growth compared with Trisomy 18 patients is above average. Centiles is the distribution of weight in the normal population. This patient had Trisomy 18 and was also an Asian should be compared with a similar population to her (i.e.
The medical reviews following discharge in August/September
2000 were favourable. SC showed signs of development and growth
D13 Letter from Dr Shirsalkar to Dr Suri on 18th September 2000
“ She has done very well since discharge
home. Initially she was being fed hourly but now she is on continuous 24-hour pump feeds and seems to be coping well with
In the clinic today, she was fixing and following
Letter to Dr Shrilaskar to Fiona Young 15th August (D17)
child has been gaining weight slowly since coming home “
Letter to Mr Pierro from Dr S Alexander 20th July 2000 (D18)
“ She seems to be doing well “
D126 19.6.00 “ Suniana a lot active, responding to touch and conversation”
D128 20.6.00 “ Active responds to stimulation “
“Baby has recovered well from recent infection and is gaining weight”
D183 24/7/00 “ Gained
10g weight “
D216 1.10.00 1400 “ Cardiovascularly stable
– heart rate 150-155pm, good colour, responsive, apyrexial, resps 40, CPAP reduced by mum from 55% to 30 % currently
with saturation’s maintained at 95-98 %. All medication given –mum has passed oral gastric tube
Medical Report by Sarah Luke 5.9.2000 Consultant Paediatrician
Presently showing good play skills fixes and follows
well. Loves moving toys, has been focussing for the past 2 months, smiles appropriately to dad though this was obviously late
starting about 2 weeks ago. Loves people and sustained focus developed a week ago. She is now beginning to track.
Started cooing approximately 2 weeks ago, prior
to that there was minimal vocalisation.
Throughout the records although Sunaina was developmentally delayed, she was showing interaction with her family members.
In addition, she did show some development and progress.
We note from the Great Ormond Street review there
is no record of communication with the family and neither are there any details of any progress in development from the community
Video evidence was supplied to us before and after
the EPO. We observed footage of the child on the 1st July 2000, 27 July 2000, 20th October 2000 and 25th October 2000.
The following observations were made
a) Sunaina had visibly gained weight from July
2000 to October 2000
b) There was good family bonding . The father and
mother were very affectionate and caring towards their child .
c) We note that in our opinion the child observed
on the 25th October 2000 SHOULD NOT HAVE BEEN PROVIDED WITH A DNR notice. The visible evidence supports the conclusions reached
above. The child visibly interacted with her family. There was fixing and following and good head control. The child was seen
to sit up for a few seconds on one occasion on the 25th October 2000. Her colour was very good and she did not seem profoundly distressed at all. This evidence should
be used in a court of law to elucidate the fact that this baby was clearly NOT dying. She seemed very alert and reactive to
her own environment.
d) It was observed that on the 25th October 2000,
the family were very unhappy. The father was very tearful and the mother looked
visibly tired. We suggest that this is evidence of the disastrous consequences of the authorities on the family causing them
unnecessary distress and emotional trauma.
THUS CONCLUDE THAT THIS CHILD WAS NOT DYING.
NOT RESUSCITATE ORDERS / WITHDRAWAL OF TREATMENT
“We are of the opinion that Suniana’s
condition is sadly futile. We would strongly recommend your “ do not resuscitate “ decision in this case”
GO31 25th October 2000 Great Ormond Street
192. This “do not resuscitate” decision was never discussed or agreed with the family
Please refer to the appendix below regarding accepted
procedures and guidelines when taking a DNR order to maintain appropriate ethics.
1 Insensitivity to Religious Beliefs: DISCRIMINATION
OF ASIAN HINDU PATIENT
We refer to an article written by Dr Andy Petros
and his colleague Dr David Inwald BMJ 2000;320:1266-8 .
Here they both discuss the ethical dilemas of a
“ Families should not be pressurised into
consenting to withdrawal of care”
Similar to this case, the Jewish family disagreed
with the DNR order. It should be noted that this was a case of brain stem death. The treatment in this case was indeed hopeless.
Nevertheless, both authors state
“ The intensive care team advocated withdrawal
of care in line with the recent Royal College of Paediatrics and Child Health guidelines. However, this was in conflict with
the family’s wishes. They had consulted their Rabbi, who insisted that Jewish law would not allow treatment to be withdrawn.
“ Our care plan
After discussion with the rabbinical authorities,
a plan of care was agreed in line with Lord Jacobovits recommendations. No action was taken to hasten cessation of the heart
“ THE AIM OF INTENSIVE CARE SHOULD BE TO
TREAT THE FAMILY, NOT JUST THE PATIENT”
“ In these unusual circumstances it is more
important to respect the cultural traditions of the family that to free a bed in the intensive care unit”
194.Comment: – when comparing the two cases
we note the following
a) This HINDU family were not involved in the decision
b) There was no discussion with Hindu Priests to
come to a compromise in the light of the family’s religious affiliations and views. In the view of Hunduism, to withdraw
treatment as in Jewish law is murder.
c) A decision was taken which sentenced a Trisomy
18 child, who was better physically,
then the Jewish child in discussion. We suggest that this mode of unequal treatment
Excluding family from discussions nor seeking their
d) the decision was made unilaterally
e) No consent to see the patient was taken from
the parents with a view to a “ do not resuscitate decision”. The parents were under the impression; their child
would be transferred to another hospital as they had requested.
f) Appendix 6B provides a summary of the current
BMA guidelines in light of the Human Rights Act 1998
It is recognised widely that medical decisions
relating to children and young people ideally should be taken within a supportive partnership involving patients, their families
and the health care team
g) It is not disputed that the risk of group mortality
in Trisomy 18 is high. Nevertheless, as an individual, she showed evidence of the following clinical characteristics
She was developing neurologically as stated in the previous section
ii) She showed a good gain in weight
iii) All her saturations were normal on CPAP or
nasal oxygen. All other observations were stable
We see that even in death she is observed to be a well nourished developing individual. All blood results were relatively
normal. She was not in organ failure.
v) Dr Shirsalker had made the decision to send
her home on the 25th October 2000 with review by the home care team. If this was so, in his clinical opinion she was not dying.
vi) If it was viewed by the clinicians that “
she was dying” then Dr Shirlasker would not have made the decision to discharge her but would instead have provided
“family centred palliative care”. Clearly there is a conflict of opinions between the clinicians with Dr Robinson
and Dr Petros advocating palliative care and Dr Shirsalker considering discharge home on oxygen and maintenance.
vii) Her chest x-rays for September 2000 and October
2000 were identical. There was no DNR on her records in September 2000 but October 2000 showed a different decision
viii) She required CPAP and Oxygen but functionally
there was no cause that would result in her impending or sudden death
therefore stipulate that she may well have died at a later stage but she was not dying in that week.
196. The concept of futility is relative. There
are individuals in persistent vegetative state where clearly there would be no benefit in resuscitation where we would advocate
withdrawal of treatment and DNR policy.
this instance, a decision without considered discussion with the family to form an informed decision, fall below the standard
of care expected of a practitioner
state that withdrawal of treatment and DNR in these circumstances under a CARE ORDER, without the parent’s involvement
or agreement, is not justified. Given the good condition of the child, she was
not “dying” as evidenced by the observations made by the staff and
doctors at King George’s Hospital. This raises Human Rights issues regarding
Article 2 ( Right to Life)
199. CONFUSION IN DECISIONS
Throughout the medical records, there has been
a lack of communication and hence a management plans for the child in question.
There is incredible confusion displayed when ascertaining
the actions of the clinicians and King George’s Trust:
1) Emergency Protection Order was obtained claiming
to “protect the child from harm” from the parents when the Trust and clinicians had no wish to maintain her life.
2) Although in the Paediatricians’ opinion
there was a “ risk of significant harm” from parents, this has no basis as evidenced above.
3) Great Ormond Street was contacted who provided
a ‘Do not Resuscitate’ Opinion without seeing the patient on the 20/10/00. Later that week, the team did visit
and verified this decision on the 25th October 2001.
Chief Executive has written to the family stating that a “do not resuscitation” policy was going to be followed.
A4 Letter dated 24th October 2000
“In the light of this, the clinical decision
is that should Suniana’s condition deteriorate, we will provide palliative care, but we will not provide intensive care,
including CPAP or ventilation or take steps to resuscitate her.
5) No discussion was made of these events with
the parents concerned
6) The parents assumed that a “ do not resuscitate”
order would be followed
7) Judicial Review to instigate these proceedings
were applied for during the week of the Emergency Protection Order stating the requirements for withdrawal of treatment and
8) On the 25th October 2000, Dr Shirsalker writes
a care-plan with the intention of discharging the patient contrary to the intentions of the Trust
9) On the 26th October 2000, the team attempt to
resuscitate the patient contrary to the stipulations of the Chief Executive in his letters to the family.
200. In conclusion, the paediatric team and the
Trust displayed gross confusion.
They failed to advise the family adequately.
ii) This misunderstanding led the family to believe
that “ the child would not be resuscitated”. Yet finally this child was resuscitated.
question the reason why she was not provided with the identical decision in May 2000 given her mortality at that point was
the highest at approximately 99% given she had a diaphragmatic hernia, respiratory distress, low birth weight.
202. Prognosis was better having survived a full
term pregnancy, a normal delivery, an operation on the diaphragm, a second complication operation on the stomach, progressing
in weight and developing slowly but better than expected for a Trisomy 18 child.
203. The DNR decision and withdrawal of treatment
was placed when she was in a much better clinical condition and thriving. There is no evidence of acute or chronic deterioration. Thus, the DNR decision was not rational at that point.
conclude the consultants, the management and the staff failed in communicating between themselves and the family and acted
unlawfully and unprofessionally in the clinical decision-making process.
Letter from Dr Shirsalkar to Dr Suri (GP) 18th
September 2000 (D13)
Medication Frusemide 1ml OD
Spironolactone 0.35ml OD
Ranitidine 0.2ml tds
Noticed Ranitidine does was 30mg on drug chart (0X dose) It had been given on two earlier occasions.
Clinical incident form complete C Ellingford
a) Why did pharmacy not notice this?
b) Why did the admitting doctor not notice this
c) Why did the consultant not notice this
d) We would class this as a medical error although
no harm came to the child. Due care and attention of the charts was not taken from admission.
conclude the consultants, the management and the staff failed in the ethical decision-making process. Without understanding the complex issues involved of consent and information-giving, they falsified medical
details when obtaining the EPO, not for the protection of the child, but only to exclude the parents who were a source of
irritation to them. The confusion in the ethical decision making process
and promoting unnecessary legal measures with false information is a gross injustice to the practice of medicine today.
206. CAUSE OF DEATH
We have established from the above discussion that
there are many misconceptions about the cause of immediate death of this child. Section 2 illustrates the chronic conditions
which in the view of the excellent levels of observation results recorded was not the cause of death in that given time frame
(20th October 2000 – 26th October2000). These are summarised below
a) All her saturations and observations were normal
b) She was seen to interact with staff
c) These are not the actions of a dying baby
d) Her chest Xray for October 2000 is better than
e) Her diaphragmatic hernia had been repaired therefore
there is no morbidity from this
f) Her VSD was clinically closed according to reports
from various clinicians
g) Cerebellar cysts – does not cause death
– it causes disability
207. All chronic conditions can be exacerbated
by an initial insult which places greater demands on the human physiology eg when running, an asthmatic condition may deteriorate
due to the requirement for a greater respiratory effort or angina pain may progressively worsen on exercise due to greater
208. To deduce the most likely cause of death on
the 26th October 2000, one must look at the overall condition of the child within the time frame of death. It is not disputed
that Trisomy 18 was a life-limiting condition nevertheless in our opinion it was very unlikely that she was dying in that time frame. Our reasons for concluding this is based on the evidence presented below.
1) The child did not worsen during the week starting
20-26th October 2000. She showed good saturations and she was not on CPAP. All observations were very good and within normal
limits ( please see observation charts for 20-26th October 2000)
2) There was no evidence of infection apart from
an isolated temperature rise of 38 C. The Post Mortem report showed that all blood cultures and virology were negative. Histology
of the lungs did not show profound infection eg consolidation. In the absence
of this we cannot conclude that an infection precipitated her death.
3) The child had showed an improvement during that
week (eg her oxygen had been turned down) and she was not on CPAP.
discuss the events of the 26th October 2000, one must list the events in detail on that date.
Our reasons for the cause of death are based on
the evidence before us. We offer the most likely
cause in the clinical environment given the circumstances. Sunaina Chaudhari was not terminally ill. We agree that her longevity was shorter
than the average child was but we dispute the fact that she was “ dying”in October 2000. There was no indication
that she would die on that particular day of 26th October 2000.
To deduce the cause of death, we wish to take this
opportunity to list the events of the 26th October 2000
210. EVENTS OF THE 26th OCTOBER 2000 ( D387 –D394)
Mrs Chaudhari Phoned
Phonecall taken by SN Razaram
Enquiry “ How many litres is Sunaina having.
1.5L of oxygen and the saturation was 95%
Tolerating feed well
Oxygen has remained between 1-2 litres maintaining
saturations mid 90s
Sats 95% on 2Litres
From 0800 oxygen turned down o 1.5 Litres
Temperature was 37.8degrees C
Actions taken due to temperature
* Baby quilt was removed and window opened
* Baby washed and changed by Student nurse J Marks
NB This entry was not written at the time which
is very unusual
Temperature 38 degrees C
Calpol 60mg given
Dr Rager was informed (8278)
Dr Rager then said he would discuss it with Dr
* Given KCL and Frusemide Via Oral gastric tube
* Dr Sam came to see Suniana
* “blood cultures and bloods should be taken
and antibiotics commenced
* Held her for 10 minutes
* Dr Hancox bleeped at 10.15
NB baby woken up as soon as she settled to sleep.
Dr Hancox tried to bleed Sunaina
“On examination, awake crying, moving limbs,
slightly pale, not cyanosed, mild dyspnoea noted. Chest Good Air Entry
Attempted X2 cannula without success
Dr Solebo came into the room to assist
O/E Pale but not cyanosed, breathing but dyspnoeic.
NB there is no evidence that the oxygen which was
at 1.5 litres was turned up . Given she was dysnoeic this would be the “ reasonable practice”
There is no saturations noted at this time and
in addition no observations were taken. D406 The last saturations were done at
10.20 and not 10.53 when she was notably breathless. Her last notes Saturations were 91%.
At this point the oxygen should have been increased to 2L
There was no nursing staff to make observations
THE DECISION WAS TAKEN TO CANNULATE AGAIN
* IV Cannula attempted., first attempt failed
* 2nd Attempt successful but Sunaina became apnoeic,
eyes ……. And stopped moving
* Airways cleared of secretions
* Given O2 by bag and valved mask
* No response for 1 min
* Called in Dr Sam and I then decided to intubate
* 3.5 gage with good air entry
* Commenced CPR
* Given 0.5ml 1:1000 via ETT
* Given 3 doses at 3mmols
* Continued CPR and manual IPPV
For 15 mins
Dr Solebo called nurse to the room
Dr Solebo Intubated
Decision made to stop CPR by Dr Sam
After this Sunaina was
“ immediately extubated and oral gastric
tube was used to withdraw gastric contents
Oral gastric tube was then removed
Sunaina was cleaned and dressed
Family parted from child
Whereabouts of the body was uncertain during this
211. Many hypothesis regarding the cause of death
have been presented. We wish to discuss the following possibilities of death which have been presented by specialists and
a) Subendocardial necrosis
b) Central Apnoea
c) Drowning by milk
d) Apnoea induced by multiple venflon insertion
We wish to deduce a step by step format that elucidates
the most probable cause of death.
TIMINGS OF VENFLON INSERTION AND PROXIMITY TO COLLAPSE
From the above it can be noted that the collapse
occurred whilst cannulation was taking place. It should be noted that the process of cannulation causing stress (and pain
reaction) to a child is widely listed in the current research.
Many papers have listed that there are greater
demands placed on the respiratory rate, the heart rate and oxygen saturations.
a) Singh H et al Comparison of Pain Response to
Venepuncture Between Term and Preterm Neonates. Indian Paediatrics 2000;37
“ Mean heart rate increased during the procedure
in all the groups…
… was a rise in respiratory rate during the procedure in all groups”
…. All newborns in three groups experienced
a significant oxygen desaturation during the procedure.
b) Potentially injurious hypoxia occur even during
essential routine care procedures
* Long JG , Philip AGS. Excessive handling as a
cause of hypoxaemia 1980;65:203-205
* Craig KD, Whitfield MF .Pain in the neonates
. Behavioural and physiological indices Pain 1993; 54:111
In a child with chronic lung disease, additional
measures would need to be in place due to the extra physiological demands placed on the child merely by intervention by cannulation.
We observe that the child was saturating well and
indeed all her observations were all normal overnight until 1053 on the 26th October 2000.
This does not indicate a “dying baby”. In a dying baby we
would expect saturations to be much lower, a dependancy on CPAP and high oxygen requirements and clinical evidence of severe
respiratory distress (ie recession and tachypnoea).
After cannulation it is noted that the child was
“ breathing but dyspnoeic “(D391).
a) There were NO saturations noted that that time
which is clinically negligent
b) There were NO recording of any observations
during this time
c) Normal practice would be that the child should
have been “continuously monitored “ while cannulation was occurring.
d) There was NO nurse to observe and monitor the
e) Despite the note above, the doctors DID NOT
increase the Oxygen to 2L or above if needed for the distress they witnessed, which is normal practice.
Given the above we can conclude the child was not
monitored and precautions were not taken to prevent a collapse. This would be termed “ reckless” and lacking in
their duty of care to ensure the safety of the patient.
214. Following these events the child became “
apnoeic” (D391). This is defined as an absence of breathing. We follow
the logical path of dyspnoeic then apnoeic which means the patient was breathless then had an absence of breathing. This clinical
observation from the records leads us to conclude that a respiratory arrest occurred as opposed to a “ cardiac arrest”.
proximity of the cannulation to the collapse was approximately 2-3 minutes. Given the trend of normal observations and no
sign of deterioration UNTIL cannulation, a linear curve relationship would lead us to conclude there were no other intrinsic
factor that caused her IMMEDIATE death.
216. The close proximity of the cannulation to
collapse leads us to an extrinsic factor which exacerbated her chronic condition.
For example, in an adult running would exacerbate
angina in an individual resulting in greater physiological demands on the body – thus presenting as chest pain.
217. This extrinsic factor is the INSULT CAUSED
BY CANNULATION. It should be noted that cannulation occurred approximately six times.
This is listed in the Post Mortem Report “
There were three needle puncture marks with small areas of surrounding bruising on the dorsum of the left hand and three similar
needle puncture marks on the dorsum of the right hand”
In the light of the patient’s condition and
warning signs after a few cannulations eg dysnoea, the cannulation should not have been continued.
The patient had been directed for palliative care
after instructions from Intensivists.
Furthermore, given that the Consultant and family
were in court that very morning for consideration of Emergency protection Orders, any interference should have been defered
until outcome of EPO extension or discharge.
There was an isolated temperature of 38°C (ie temperature
was not constantly high) and the child was not obviously toxic. Appropriate measures
to reduce temperature eg mild tepid sponging and calpol, was given at about 10am but this was NOT given time to work. Her temperature usually subsided in the past.
0405 “ Sunaina spiked a temperature of 38degrees
C. Given Calpol with good effect “
NO BLOOD CULTURES WERE DONE ON THIS OCCASION as
the natural characteristic of this patient was an occasional spike in temperature. We conclude therefore that the urgency
of blood cultures was not indicated given there was no indications of sepsis. In
addition, other routine measures were not done eg dipstick of the urine .
In view of this, Cultures or Cannulation SHOULD
NOT have been done given the mere fact that it was the intention of the staff to discharge the patient home following the
hearing that day.
The more prudent approach would have been to observe
the patient further and if her temperature had not subsided, to provide regular calpol.
All PM report cultures were negative which thus
obliterates the urgent need for cultures and cannulation.
STATE THAT 6 CANNULATION ATTEMPTS WAS EXCESSIVE.
This would have definitely caused the child distress
increasing physiological demands phenomenally.
The normal practice and options would have been
to attempt 2 or at most 3 venepuncture (needle pricks) attempts, and return later after the child became more settled. Checking oxygenation then progress after stabilising the patient should be done by
any reasonable doctor.
219. In this child however, her PHYSIOLOGICAL DEMANDS
were not met by the provision of adequate oxygen either intentionally or unintentionally.
Either, the quantity of Oxygen supply was inadequate
for her, thus leading to a profound hypoxia or the possibility exists that the oxygen via nasal prongs had been dislodged,
causing the same result, but there is no documented evidence of this.
220. WE THEREFORE STATE THAT THE MOST LIKELY CAUSE
OF DEATH WAS DUE TO AN INSULT CAUSED BY REPEATED CANNULATION, PAIN CAUSING HYPOXIA AND INCREASED OXYGEN DEMANDS, THEN PROLONGED
OR UNRECOGNISED HYPOXIA (PALLOR IS ALSO A SIGN OF HYPOXIA) LEADING TO A PROFOUND
BRADYCARDIA OR VAGAL REACTION (SLOW HEART RATE) THUS PRESENTING AS AN APNOEA.
221. THE APNOEA THEN PROGRESSED TO FULL RESPIRATORY
ARREST THEN IN TURN CARDIAC ARREST CAUSING AN IRRETRIVABLE COLLAPSE.
222. Therefore, given the close proximity between
the time of sudden collapse, which related to the venepuncture, the probability that this is the direct cause of death is
extremely likely. This has a greater probability of 95%, in the absence of deterioration
of any of other factors as listed above.
223. IT SHOULD BE NOTED THAT CANNULATION WITHOUT
EXPRESS OR IMPLIED CONSENT FROM THE FAMILY LEADS US TO THE “ NON CONSENT “ ISSUE.
224. THIS THEREFORE IS AN ASSAULT DIRECTLY LEADING
TO THE DEATH OF THE PATIENT.
225. CANNULATION FOR THE REASONS STATED ABOVE WAS
NOT AN EMERGENCY AND NOT URGENT THEREFORE THE CONSENT ISSUES CANNOT BE WAIVED IN THESE CIRCUMSTANCES.
226. THE POSSIBILITY OF MANSLAUGHTER SHOULD THEREFORE
BE INVESTIGATED IN THE LIGHT OF THE CIRCUMSTANCES SURROUNDING THIS CASE.
227. RECKLESSNESS HAS OCCURRED IN THE FOLLOWING
a) Lack of
b) Inability to increase oxygen when required
c) Inability to gain consent from the parents in
the event of cannulation (interference)
The fundamental rights of any person in the United
Kingdom is required to be protected at all costs. With the advent of the Human
Rights Act 1998, this case raises a number of breaches in Human Rights legislation commited by the authorities.
This family has been denied their rights to be
with their child for one week ( 20th October 20000- 26th October 2000) due to a fraudulent Emergency Protection Order which
in our opinion was obtained due to Redbridge Trust’s irritation with the family. Irritation and convenience is NOT an
indication for an Emergency Protection Order. False information was provided
to the Justice perverting the course of justice for the Trust’s own convenience.
There is no doubt that this hospital was inexperienced in dealing with culturally sensitive issues and more importantly
the care of a Trisomy 18 child. In our opinion, we note that throughout the records,
there is mention of “ short staffing” and hence we conclude that Redbridge NHS Trust have been unable to cope
with the demands placed on them. The convenience to obtain an Emergency Protection Order was for their convenience in obtaining
a Do not Resuscitate order and also decreased demands from the family.
The following officials and staff have failed in
their duties to protect a vulnerable patient .
a) Chief Executive Mr Peter Murphy
* Failure to protect Mrs Chaudhari from harrassment
and victimisation by the staff due to her complaints
* Failure to provide a resolution and compromise
for the family
* Failure to provide accurate information eg he
wrote to the family about the DNR management when no court order was obtained.
* Failure to deal effectively and investigate the
complaints through a complaints procedure.
* Failure to ensure an urgent transfer to another
hospital in an emergency where there was a severe relationship breakdown
b) Dr David Robinson
* Failure to provide the family with a resolution
* Failure to terminate his relationship with the
family when a relationship breakdown occurred
* Misleading Great Ormond Street regarding information
about the child
* Collusion for innacurate information for the Emergency Protection Order.
* Lack of communication with his team causing serious
c) Dr Anand Shirsalker
* Providing false and misleading information regarding
oxygen effects on infection .
* Collusion with provision of innacurate information
for the Emergency Protection Order
* Confusion in his decisions to discharge a child
while in the meantime agreeing to a Judicial Review.
d) Dr Andy Petros and Team
* Failure to communicate with family regarding
* Unilateral decision taken place
* Failure to interview family
* Collusion with false information provided for
EPO. Lack of duty of care to check and verify information provided
* Inccurate and misleading information provided
eg Oxygen and pulmonary fibrosis etc
* Breach of Patient Confidentiality to another
Trust’s solicitor without express consent of the parents
e) Anne Mahoney and Staff at Clover ward ( who
will need to be interviewed)
* Inaccurate information in medical records
* Harrassment/ Victimisation of Mrs Chaudhari and
f) Maria Murphy
* Failure of assessment
* Failure to communicate information with family
* False information for Emergency Protection Order
All staff need to be interviewed to ascertain liability
of each individual more accurately. In
addition a full investigation into these matters is required which to this date has not been done.
We conclude that the care of this child has been
substandard . There has been severe communication difficulties and a relationship breakdown. The BMA publication “Consent
, Rights and Choices in Heathcare for Children and Young People states ( page 5) “ in practice however, secrecy , bad
communication and patient’s suspicion that important questions are being avoided can contribute to fear and anxiety”.
Dishonesty undermines trust and can create a barrier between patients and health professionals.
Due to this we observe the evidence of sheer malice
in making one sided decisions about a child without the involvement of the family. The decisions were detrimental to the best interests of the family. We note the meaning
of “ best interests has been abused and misused throughout the records. The
BMA publication on “ Consent, Rights and Choices in Health Care and Young People states “ We seekl to demonstrate
that patients’ best interests are not only defined in terms of physical benefit – vital as that usually is –
but also in terms of what best accommodates their other needs. 1.2 states that “ Regarding the definition of best interests,
it is customary to assume that a person’s best interests are usually best served by measures that offer hope of prolonging
life or preventing damage to health.
Factors to be considered when assessing “
* The patient’s own ascertainable wishes
, feelings and values
* The patient’s ability to understand what
is proposed and weigh up the alternatives
* The patient’s physical and emotional needs
* THE VIEWS OF PARENTS AND FAMILY
* The implications for the family treatment or
* RELEVANT INFORMATION ABOUT PATIENT’s RELIGIOUS
OR CULTURAL BACKGROUND
Others are listed also ( page 4)
We therefore observe a failure in the assessment
of “ best interests” of the child. Others includes the likelihood and degree of clinical success, the treatment’s
invasiveness and side effects and the wishes and needs of the family. Additionally some people believe that there is an intrinsic
value in being alive and therefore prolonging life always benefits patients, regardless of any other factors (p116). The majority
of children with even every severe physical or mental difficulties are able to , or may in the future , experience and gain
pleasure from some aspects of their lives.
The health care rights of children and young people
are also set out in advisory statements such as the World Medical Association’s Declaration on the Rights of the Child
to Health Care. 1.3.6 ( page 14) states
“ To be looked after appropriately, without
DISCRIMINATION of any kind including grounds of disability” and a right to confidentiality.
Decision making for children is unable to decide
for themselves is usually , and rightly , left to parents and the health care team. It is widely agreed that parents need
time , respite facilities , possibly counselling and certainly support from health professionals, but in most cases they are
best placed to judge the child’s interests and decide about serious treatment ( p106).
Every effort must be made to obtain a resolution
when a dispute arises. This was not done. Decisions made were secretive and often
compounted the mistrust in the medical professionals. Every fundamental right
for the family’s privacy has been violated in terms of confidentiality and consent. It is paramount that in clinical
practice this is maintained.
The Emergency protection order was obtained to
place a Do Not Resuscitate decision on the child. We can find no other reason
for this method of action by the clinical team. In effect the decision made was thus secretive and only explained to the parents
at the twelfth hour.
The main legal liability lies in the following
avenues where the family are free to seek recourse
a) Victmisation/harrassment and bullying
b) Defamation of
the family on numerous occasions.
c) False and misleading information presented for
the Emergency Protection Order which may amount to fraud. Perverting the course of justice
d) Human Rights Legislation
e) Non Consent
f) Breach of Confidentiality
g) Assault/battery due to non consent
h) Recklessness and direct causation of death from
this assault – possible manslaughter needs to be investigated.
i) Disability Discrimination ( Disabilility Discrimination
j) Cultural and Racial Insensitivity ( Race Relations
The insensitivity of the professionals has been
overwhelming. The reasonable doctor would not inform the parents of the death of their child in a court room. The correct method would be to summon them to the hospital where there would be nursing support and break the
news. Although the Trust solicitors have listed her grief reaction and implied it was abnormal. We state that in these circumstances
her reaction was entirely reasonable given the draconian measures taken to keep her from her only child namely the EPO etc. Following the death of her child , the social services documentation lists “
Munchausen’s byproxy”. We would like to stipulate that there is no mention of this throughout the documentation
and there is no evidence to verify this defamatory remark. In addition social workers are NOT qualified to diagnose this condition.
The insensitivity of all professionals involved in this case has been astounding.
we have shown the failures in many areas of Redbridge NHS Trust and King Georges Hospital NHS Trust and their staff
using a Emergency Protection Order to provide a “ Do not Resuscitate” Order to a five month old child without
the consent of the parents. We note that there has been substantial clinical decision confusion, conflicting views and opinions
and a severe breakdown in relationship. This has led to a breach in confidentiality, lack of consent resulting in an assault
directly leading to death. In our opinion, no child or family should be subjected to this form of treatment in the United
Kingdom which is a denial of the fundamental rights of the child and parents.
230. OTHER ISSUES RAISED BY THE FAMILY
a) Potassium as the cause of death
a) Potassium were provided as oral supplements
according to the drug charts
b) This is within the normal range.
c) We observe that all Forensic Investigations
d) The determination of potassium after death is
e) There is therefore insufficient evidence for
Potassium to have caused the death of this child
b) Milk as a cause of death
This is unlikely. We have explained this to the
relatives. The stomach had not been aspirated prior to death due to the rush of the arrest. Subsequently, the milk aspirated
into the respiratory system. This is a common complication of resuscitation. This
was the reason for the mother observing milk flowing from the mouth and nose.
c) Retention of Organs
It would be prudent for the pathologists and mortuary
attendants to allay the family’s concerns immediately regarding the child’s organ removal and retention in the
light of recent public sensitivity in this matter eg if her eyes and cornea were retained, it would be prudent to clarify
the whereabouts of the child’s eyes to the family and to return them as soon as possible. We note that there is no ophthalmology pathology / history written in either of the pathology documents
RECOMMENDATIONS to facilitate investigations
a) We recommend that further clarification is required
with respect to the discrepancy in dates of obtaining specimens and also the Post Mortem. The police and Coroner need to clarify
to the family the dates written on the PM report . These are Date taken is stated as 26/10/00 and date received is listed
as 30/10/00 which was the date of the post mortem. It would be prudent to clarify
this to the family immediately.
b) The family require and are entitled to an account
of the whereabouts of the body from 1900 on the 26th October 2001 onwards. This is in the form of evidence of who accompanied
the body and also access to the Mortuary book. This is for the family’s own peace of mind. There have been conflicting
accounts regarding the details and whereabouts of her body. We suggest that a police officer take the time to answer the family’s
questions regarding these matters.
c) There has been no assessment of the amount of
adrenaline present in the child post resuscitation to show that the child was actually resuscitated. We cannot see this drug
in the forensic reports. We would be grateful for any clarification of the presence of adrenaline.
d) The rapid clearance of the room after resuscitation
occured. Efforts should be made to deduce what equipment was used on the 26th October 2001. Efforts should be made to investigate
the details of the resuscitation. It would be prudent for the location of the orginal baby’s clothes to be available
e) We require all records of the 26th October 2001
from the switchboard at King Georges Hospital . It is essential we established who was bleeped on that day by the junior staff.
f) Full and complete statements are required from
each doctor/ nurse involved in the resuscitation process to deduce the times and actions by them. At the time of the report
this was not done by the police. King Georges Hospital have since clarified that there have been no investigation by the police
or statements made. It would be useful to obtain the statement of Ms Judi Fox who was the nurse allocated for Sunaina on the
morning of the 26th October 2001.
g) All statements are required for the individuals
listed at the start of this report. This is imperative to obtain an overview of the situation at hand
h) A bed state for Great Ormond Street Intensive
care is required. .
This will cause a lacuna in the investigative procedure and thus a discrepancy in the case formulation which will be
a breach of a right to a fair trial.
of the stool/ chair, supposedly used to barrade the door is required as an exhibit.
At the time of this report Redbridge Trust had refused this request to the family.
i) It would be prudent of Redbridge Trust to correct
the numerous inaccuracies in spelling of Sunaina’s name and her family. By
comparison we have never noted so many spelling errors attributed to the Asian nature of the names. Nevertheless, in accordance
with the Race Relations Act and cultural sensitivity, it would be prudent to correct all inaccurate spellings, which are too
numerous to mention. The name was spelt correctly at the front of the records
therefore it follows that further numerous mistakes, should be corrected. This includes Redbridge NHS Trust, Great Ormond Street to all investigative reports.
i) We would like details of the following –
how many Trisomy 18 children has Dr Robinson, Dr Shirlasker and Dr Petros treated. We
require details of the number and Hospital ID or dates to identify their expertise with dealing with a significant number
of such patients.
We require details of APLS certification details
of all staff involved in resuscitation of the patient. We require proof that all certification is up to date.
j) The Ethics Committee report from Great Ormond Street is required
k) We require a picture of the chair used to “
barricade “ the door. This has been denied by King Georges Hospital.
l) Staff cover statistics for Clover ward Redbridge
m) All details of rotas for the doctors and nurses
oncall over that period as there are some discrepancies which the family wish to view. Explanations of why Dr Rager was oncall
after his shift was over . We suggest this may have been due to ward round commitments after his oncall. This needs to be clarified.
n) All Social Services Documents are required
f) We note that there was an admission by Dr Solebo
at taking blood prior to death. He is recorded as saying this but has since refused. It would be prudent for the Police to
deduce the existence of this blood result .This can be done
g) Forensic referral for the Drug charts where
Potassium chloride is altered
h) Missing page of the medical records between
D326-D327 . There is no signature at the bottom of D326 and D327 begins midsentence. Please clarify these pages.
i) Telephoning the lab directly
ii) Lab log books where all specimens are logged.
We require a copy of this page on the date when the samples were taken
iii) All computer biochemistry/ haematology results
for this day and this patient are required
i) It is imperative that the Police are able to
deal with the family with sensitivity. So far the evidence from the correspondence from the Coroner and Police to the family
have shown a great deal of antagonism. It is not unreasonable for the family
to perceive that their child was killed given that a “ Do not resuscitate “ order implies that no efforts will
be made for life. In our view, the family has been failed by King Georges Hospital
and Great Ormond Street. They have had two bereavements in the family and faced
with a very unsympathetic authorities from the beginning. We suggest that it
is imperative for the police force to deal with these issues point by point until such time that the family have developed
trust within the excellent work in investigation that is possible from the British Police. It is important that ALL there
questions are answered logically, with evidence to ensure that the family are provided with a good explanation for each question. We have attempted to allay some of their concerns which have arisen due to lack of
communication between them and their own doctors. We do not wish for this mistake
to occur with the police . It is imperative that in line of the Macpherson report, their cultural background is taken into
account. In addition, the family are suffering from emotional shock of the death
of their child compounded by the conflicts in the answers to all questions they have asked. We have viewed the correspondence
the family have received from Dr Stearn , who is the Coroner appointed . We consider
the correspondence to be very antagonistic towards the family. In light of this, the family CANNOT receive a fair trial with
this coroner preciding over the case. WE THUS REQUEST AN INDEPDENDENT CORONER BE APPOINTED TO PRESIDE OVER THIS CASE AS A
MATTER OF URGENCY. We note a breakdown in relationship between the coroner and
the family and hence this is NOT in the best interests of the family. We hope therefore that a new and fresh investigation
is opened for this family to answer all the questions that we have not been able to explain due to lack of statements and
a further investigations which are in the police jurisdiction.
It should be noted by all police officers that this family require good communication skills and sensitivity. One cannot expect a family who has been through the death of their child to view the situation as we would
. It is their fundamental right to obtain the answers. We suggest that the family be questioned and statements obtained in
detail. A female officer would be more appropriate to the sensitive issues of the loss of a child to question the mother in detail and we suggest that this is done to obtain the maximum amount of information
and evidence that the family have in their possession.
IT MUST BE NOTED THAT their allegations are a in
the form of asking the authorities the questions they would like the answers to. Their mistrust has stemmed from the secrecy
of the health professionals. It is not an unreasonable reaction and it must be stressed that the family DO NOT HAVE A PSYCHIATRIC
ILLNESS as imputed previously. Their allegations therefore remain because these
questions have not been answered in any way or form. These answers are required to be logical and rational and explained in
detail in order for the allegations to be held or refuted.
We are thus taking this opportunity to stress that
it is imperative that your officers deal with this case with great sensitivity and logic so we are all able to pursue justice
for a dead child as opposed to compound the antagonism that has been created.
j) We have had great difficulty in obtaining documentation,
evidence from the hospitals who have in effect refused to co-operate with the family. We thus recommend that these documents
are obtained under PACE.
k) We doubt that an additional post mortem would
be beneficial in the investigation of this case. We would strongly advocate a burial of the body as soon as it is feasible
to assist with bereavement .
l) We request that all slides etc are reviewed
by an Independent Pathologist of their choice . It would be useful to obtain
an independent opinion of the histology.
m) We would advocate that a number of paediatricians
assess the video footage of the child to assess development . This is to be done without the knowledge and background of the
hospital or specialists.
n) It would be useful for the police to re construct
the scene of the resuscitation to verify all events of the case during that time frame.
n) IN SUMMARY
* A New investigation which a police team is required
as there are many elements of a criminal nature.
* An Independent coroner to be appointed or the
inquest held at a different court . This is in line with Article 6 of the Human Rights Act 1998
* All documents are required to be seized under
PACE immediately from the Social Services, Great Ormond Street and King Georges Hospital
* Further questioning and inquiries are required
before the inquest is carried out. We would refer this case to a full inquiry
due to the number of individuals involved and the complexities.
* It is imperative that the relationship between
the police and the family is reinstated The interests of a dead child is served well by the justice system of the United Kingdom.
* WE SUGGEST THE FAMILY TAKE THE FOLLOWING AVENUES
a) Presentation of this document to Scotland Yard
and the Home Office in London
b) Commencement of NHS Complaints Procedure to
the NHS Health Ombudsman
c) Commencement of Social Services Complaints Procedure
d) Civil Litigation to be pursued to the European
e) Criminal Litigation
We will be available for any enquiries regarding
this report and will be more than happy to assist the police or legal advisors in the future.
This report has been formulated in memory of Sunaina
Chaudhari . May she rest in peace.