FAI DETERMINATION SUMMARIES

The Sheriff made no recommendations following the deaths and determined that there were no defects in any systems of working which contributed to the deaths.

With regards to Sonny’s death, Sheriff Cameron determined that there were no reasonable precautions which could have been taken to prevent the death.

With regards to the death of Cailyn, the sheriff found that a reasonable precaution which could have been taken to prevent the death would have been for Cailyn to have been admitted to the Clinical Decision Unit for further observations after presenting at the Emergency Department.

Background

Sonny Campbell

Sonny died at 1245 hours on 6 December 2016 within the Emergency Department of the Royal Hospital for Children, Glasgow. He was 1 year and 10 months old. The cause of death was acute haemorrhagic leucoencephalitis (AHLE), a rare brain condition caused by infection.

Sonny lived in Glasgow with his mum and twin brother. 

The day prior to his death, his mum took him to see his GP after he had been unwell for several days. He had been vomiting, had a cough and runny nose and a high temperature. The GP referred him to the Royal Hospital for Children, suspecting that he was suffering from viral gastritis and an upper respiratory tract infection.

At hospital, he was assessed as suffering from a viral illness and discharged later that evening with advice to return if his condition worsened.

The following day, Sonny’s gran was taking care of him in the morning while his mum ran some errands. His mum returned home at 11.20am and noticed that Sonny looked pale and his skin had a yellow tinge. His breathing was also laboured. His mum called 999 and he was taken to the hospital by ambulance, requiring ventilation on the way there.

On arrival at the hospital, he was taken to ‘resus’ where a team of clinicians were awaiting his arrival. He had no pulse on arrival, his lips were blue, and his heart had stopped beating. Resuscitation was attempted but Sonny was pronounced dead a short while later.

Given Sonny’s quick decline due to AHLE, the sheriff found that even if he been admitted to hospital the day before he died, rather than being discharged, it is unlikely that any treatment could have prevented Sonny’s deterioration, collapse and death.

Cailyn Newlands

Cailyn died at 2042 hours on 6 December 2016 within the Emergency Department of the Royal Hospital for Children at the Queen Elizabeth University Hospital, Glasgow. She was 1 year and 11 months old. The cause of death was pneumonia.

Cailyn lived in Renfrew with her mum, dad, and brother. In the days leading up to her death, her mum had taken her to see her GP and had attended at the Emergency Department within the hospital on three occasions.

On 2 December, her GP arranged an ambulance to take her to the hospital after she presented with a fever, fast breathing and a rash which faded when pressed. Cailyn had been sleeping lots and was groggy and not herself.

When she was later examined in hospital, she was bright and active with a reduced temperature and breathing on her own. The decision was taken to discharge her, with her mum receiving advice to return if her condition worsened.

On 5 December, Cailyn’s mum returned to the Emergency Department as her daughter had not improved. Cailyn was examined and was found to be alert, well and hydrated. A number of assessments were carried out and the doctor formed the view that she was suffering from a viral infection. Cailyn’s observations were satisfactory, and she was discharged.

However, on the way home, Cailyn vomited in the car and her mum decided to return to the hospital. She was assessed again and the doctor sought additional advice from a colleague, who suggested that she required a prolonged period of observation. The doctor giving the advice was of the view that this would mean up to 24 hours of observation in the Clinical Decision Unit, however this was not expressly said.

The medic treating Cailyn decided to keep her in the emergency department for observation for a further 4 hours. During this period, Cailyn’s care passed to another doctor due to a shift change and at the end of the 4-hour period, she was again assessed, and her observations were within normal limits. She was discharged home.

On 6 December, Cailyn’s mum noticed she had developed a rash, and she attended again at the hospital. Cailyn was taken to resus at 1915 hours where her oxygen levels could not be obtained and her heartrate was high. During her time in resus, her condition deteriorated, and full resuscitation was attempted for around 40 minutes. Finally, after discussion with Cailyn’s parents, the decision was taken to stop, and Cailyn was pronounced dead.

Reasonable precautions

With regards to Sonny’s death, Sheriff Cameron determined that there were no reasonable precautions which could have been taken to prevent the death.

With regards to the death of Cailyn, the sheriff found that a reasonable precaution which could have been taken to prevent the death would have been for Cailyn to have been admitted to the Clinical Decision Unit for further observations after presenting at the Emergency Department.

Defects in systems of working

There were no defects in any system of working which contributed to the deaths.

Recommendations

The Sheriff made no recommendations following the deaths.

Additional issues and condolences

Sheriff Cameron highlighted that the delays in proceeding with the inquiry were ‘unacceptable’ and will have compounded the families’ grief and trauma. An additional submission was made by the Crown Office and Procurator Fiscal Service, setting out the reasons for the delay. COPFS advised that a number of measures had been implemented as a consequence of the lessons learned in this case.

To conclude, the sheriff offered his deepest condolences to the families of Sonny and Cailyn.

The full determination is available on the Scottish Courts and Tribunals Service website and is the only authoritative document.