Boy died after 'muddled and confusing' transfer

A boy’s death "would have been prevented" if not for a "muddled, confusing and jumbled" handover between paramedics and A&E clinicians, an inquest heard.

Regan Smith, 11, died of multiple organ failure on 31 January 2023 having developed diabetic ketoacidosis (DKA) and then acute liver failure.

Suffolk coroner Nigel Parsley concluded the Felixstowe schoolboy’s death was a result of a "missed opportunity" to provide him with medication.

Regan’s DKA initially went undiagnosed after his "abnormal" blood glucose level was not disclosed by paramedics upon arrival at Ipswich Hospital. It was also recorded as "normal" in Regan's electronic patient care record (EPCR).

He had first started showing signs of illness on 23 January when his parents noticed his strange and laboured breathing.

His dad Gavin took him to A&E and he was then diagnosed with viral laryngitis by a nurse practitioner the next day.

Then, on 25 January, paramedics took Regan back to hospital after his blood glucose level was found to be "higher than it should have been".

During what was described as a "difficult" handover process, the hospital told the inquest that ambulance personnel did not tell them about Regan’s high blood glucose levels.

After assessing Regan, nurses and doctors considered his laboured breathing to be a result of anxiety and he was discharged, but collapsed at home the next day.

He was again taken to Ipswich Hospital where this time it was established he had undiagnosed diabetes and was now suffering from DKA, which then led to liver failure.

After being transported to Addenbrooke’s Hospital in Cambridge, Regan was moved to King’s College Hospital in London before his death there on 31 January.

After giving evidence at the inquest, Dr David Inwald, of Addenbrooke’s Hospital, and Prof Akash Deep, of King’s College Hospital, were thanked by Regan's father Gavin.

Addressing the latter, he said: "I know you were deeply affected when he died - you started crying before I did - I wish I could give you another hug.

"You tried your best; he was just too far gone."

Towards the end of the hearing Mr Parsley said he was "amazed at the quiet dignity" shown by Regan’s parents, but added that the death could have been avoided.

Providing a narrative conclusion he said: "Regan’s death was the result of an untreated natural cause following a missed opportunity to provide medication which would have prevented his death from occurring.

"When he attended [Ipswich] hospital on 25 January the unit was especially busy with other sick children.

"Staff could not take their scheduled breaks and the pressure on the department and its staff was a factor to there being an inadequate handover.

"This led to a missed opportunity to provide treatment. Had that been given it would have saved his life."

The East of England Ambulance Service has now issued its "condolences" to the family.

A spokesperson said: "Our review found Regan’s blood sugar was reported as normal in the EPCR in error, however the EPCR also noted the correct levels, which were abnormal.

"These notes were signed for by a nurse."

Nick Hulme, chief executive of East Suffolk and North Essex NHS Foundation Trust, which runs Ipswich Hospital, also sent his "deepest and sincerest sympathies".

"We have taken steps to change the handover process for patients who arrive by ambulance," he added.

"Staff have also undertaken further training detailing the signs and symptoms of previously undiagnosed diabetes.

"We understand this does not change what has happened, but we are committed to learning from this very sad incident in any way we can."

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