Nurse who contributed to child’s death put other patients at risk

An NHS Direct call handler who contributed to the death of a three-year-old boy put other patients at risk by failing to make 999 referrals, a tribunal was told.

Daisy Chipunza did not respond properly when she took a call from the partner of a man who had taken 30 paracetamol.

She did not call an ambulance, make a mental health referral or investigate the man’s medical history, the Nursing and Midwifery Council was told.

Sam Morrish died from severe sepsis during a flu epidemic in December 2010 following a catalogue of blunders.

NHS Direct nurse advisor Daisy Chipunza admitted contributing to Sam’s death after failing to recognise the seriousness of his case and giving his mother incorrect advice.

Sam had been treated by two GPs at The Cricketfield Surgery, Newton Abbot, Devon and his parents had also sought advice from NHS Direct and Devon Doctors Ltd, a local out-of-hours GP service, before he was finally taken to Torbay Hospital at 10:30pm on 22 December, 2010.

He died on the morning of 23 December 2010 as a result of group A streptococcal septicaemia.

Following the death, a June 2014 report by the Health Service Ombudsman, titled ‘An avoidable death of a three-year-old child from sepsis’, found that ‘every organisation that provided care to Sam failed in some way’

The report concluded: ‘Had Sam received appropriate care and treatment, he would have survived.’

Christopher Doye, a nurse with 29 years experience told the hearing: ‘She should have considered calling an ambulance, albeit against the patient’s wishes.’

Mr Doye also said that Chipunza should have consulted a lead clinician and called an ambulance in any event.

He added: ‘I think there should have been more critical thinking around the overdose.

‘More exploration of the reasons, the amount the individual took, any other substances ingested that might have added to the symptoms that were present at that time.

‘It may have been relevant to discuss past medical history, especially if he had self-harmed in the past.’

‘The man had ingested more than recommended amount of painkillers and there were symptoms such as slurring of speech that suggested it needed to be investigated and needed further discussion.’

‘Some parts of the country have access to out of hours mental health, access to support.

I can’t comment on this particular case because I can’t remember where he lived. But we never got to that point in the call.

Doye said the failure to refer the call presented an immediate risk to the patient.

‘The overdose of paracetamol ingested would cause increased symptoms and some sort of damage or death.

‘There was a significant ingestion of paracetamol, the gentleman was slurring his speech.’

He added: ‘I feel that there should have been greater exploration with the caller and then that might have opened doors for other options. But an ingestion of 30 paracetamol warrants an ambulance.’

The NMC has heard how Chipunza ‘failed on a number of occasions to recognise the seriousness of cases.’

She failed to respond with the ‘appropriate advice and action’ when working both as an NHS Direct call handler and later for South East Coast Ambulance Service between October 2010 and March 2014.

Chipunza has admitted giving incorrect answers to questions and contributing to Sam’s death as a result.

The hearing continues.

ends