Norfolk Coroner’s Court has issued its conclusions in the tragic case of an eight-year-old boy from Harleston, noting that the gravity of the child’s condition and the need for surgery were not recognised by paediatric staff at the Norfolk & Norwich University Hospital.
The inquest had heard that Charlie Goodwin died at Addenbrooke’s Hospital, Cambridge, on 6 September 2019, following a move from the Norfolk & Norwich, where emergency surgery had been conducted hours earlier.
In her written statement for the Coroner, Charlie’s mother Nicola Goodwin explained how the happy, football-mad youngest of her six children had been seemingly healthy until a vomiting episode in December 2018 followed by abdominal pains and prolonged loss of appetite.
Early in 2019, Charlie’s abdomen became distended and the family’s GP shared his mother’s concern about this at a March 2019 consultation. Blood tests ruled out food intolerances, so further investigations began at Norfolk & Norwich University Hospital.
Concerned about worsening abdominal pain and uneaten school lunches, Nicola sought an early hospital appointment and Charlie was seen at Norwich on 18 July and given an abdominal X-ray. The report showed large bowel dilatation, which Nicola discovered could be due to a blockage.
No follow-up hospital appointment was forthcoming, but on 25 July Nicola took Charlie to the nurse practitioner because he was feverish with possible symptoms of a urinary infection. The nurse suggested heatstroke as the likely cause.
Over the next few days, Charlie’s symptoms intensified and a call to NHS111 prompted a visit to the local Beccles Hospital, where checks found nothing wrong, as did a subsequent doctor’s appointment at which a urine sample was taken and antibiotics prescribed as a precaution.
When Charlie’s temperature hit 40.5oC the next day and his abdominal pain became severe, Nicola suspected a blockage and took him straight to A&E, where checks for infection were negative and examination by several doctors also found nothing, so he was discharged.
Fever and pain on 2 August led Nicola to take Charlie back to the Norfolk & Norwich, where a children’s emergency doctor suspected meningitis, ordering a head scan and lumbar puncture. The radiologist refused a scan, doubting the necessity, but Charlie was admitted later that day.
Overnight on 4 August, the paediatric surgeon was called; he noted Charlie’s distended abdomen and ordered an abdominal X-ray and MRI scan, though the scan never happened and Nicola was not told why. A heart scan was done and revealed a slight murmur, but no action followed on that.
Inconclusive abdominal ultrasounds were also taken, though Nicola learned weeks later that malrotation meant Charlie’s intestines had not formed properly. Some blood tests but no further scans were carried out before Charlie was discharged on 7 August, described as ‘a medical mystery’.
Pain and lack of appetite continued and on 14 August Charlie had a barium swallow test, ordered earlier, which produced a ‘normal’ result but did not cover all of the bowel. A urodynamics test followed for continence issues, which Nicola suspected were linked to the other symptoms.
Charlie returned to school in September, but was not eating his packed lunches. On 5 September, he also left his dinner and began vomiting though with nothing to bring up. A 999 call, prompted by Charlie screaming out in pain and vomiting, brought only an instruction to use her GP or out-of-hours surgery.
Charlie vomited repeatedly and continued to scream, groan and writhe in pain when driven instead to Norfolk & Norwich A&E, which sent him straight to the Children’s Emergency Department. His temperature and blood pressure were very low and heart rate very high. He was put on intravenous fluids, and surgical review was sought, but the paediatric surgical registrar was already busy.
Despite Charlie’s presentation and a doctor’s request for urgent surgical review at around 22:15hrs, it was not until midnight that the paediatric surgical registrar reviewed Charlie, noting that there was no need for surgical intervention and put forward a plan for conservative treatment. Charlie’s situation worsened throughout the night, several further requests for surgical assessment were made and hours later at 2am following escalation to the paediatric surgeon, the surgeon examined Charlie’s enlarged, hard, blue tummy and declared that urgent exploratory surgery was needed as the cause was unclear.
During the preparation for surgery, Nicola exclaimed that Charlie’s pupils were dilated and a nurse found them unresponsive. Administering oxygen brought a brief reaction, but a doctor sounded the emergency alarm and Nicola had to leave.
A little later, a nurse came to tell a stunned Nicola that Charlie’s heart had stopped and they were responding to that. Despite two cardiac arrests, the plan for surgery stood, but Nicola was told that her very sick son might not make it.
Charlie went to theatre at 5am and an hour later was in recovery, a doctor telling the family he had intestinal malrotation causing a twisted bowel. Later that morning, they were told he would be transferred to paediatric intensive care unit (PICU) at Addenbrooke’s Hospital.
A third cardiac arrest occurred as Charlie was switched to the children’s ambulance equipment, another while switching at Addenbrooke’s and a fifth after arrival in the PICU. The family were told further CPR would mean no quality of life due to brain damage and multiple organ failure.
At the bedside, the distressed family witnessed blood pouring first from Charlie’s operation wound and then his nostrils. His parents made the agonising decision not to resuscitate after his next cardiac arrest and were there when he sadly died at 6.20pm on 6 September.
“There were missed opportunities to give young Charlie Goodwin the timely and appropriate medical treatment that his intestinal malrotation required,” asserts specialist solicitor Craig Knightley of Tees Law, acting for the bereaved Goodwin family.
“The final opportunity was at the Norfolk & Norwich University Hospital on that fateful evening in September last year. Prompt and effective emergency surgery could possibly have averted the catastrophic outcome that followed a delay of several hours.”
“The assessment by the paediatric surgical registrar was not acceptable, based on the clinical circumstances,” Craig Knightley explains. “The paediatric surgical registrar did not recognise the severity of Charlie’s illness and this error delayed the treatment which could have saved Charlie’s life.
“Following the sad outcome, the hospital’s medical director requested an ‘invited clinical record review’ of the case by the Royal College of Surgeons. The RCS report dated 29 June 2020 formed an important part of evidence for the inquest Coroner.”
NHS Trust accepts RCS findings
The RCS review team looked into various aspects of Charlie’s treatment and their report made recommendations to address both patient safety risks and aspects of the case that pointed to a need for service improvements.
The review team were concerned by the six-hour gap before Charlie was seen by a consultant on the evening of his emergency admission on 5 September 2019 and recommended that: “In order to facilitate service improvement and reduce the possibility of a similar tragic catastrophic incident, the Children’s Early Warning Score (CEWS) is reviewed and may be refined by the addition of information from blood gas (lactate) analysis to trigger an automatic senior review escalation.”
Other recommendations for action by the Trust to improve service included: undertake a review of the out-of-hours junior staff cover for paediatric surgery; reassess the adequacy of facilities for critically-ill children in the Children’s Emergency Department at Norwich; and ensure that information in clinical notes avoids judgmental language and remains factual.
Having received and read the RCS report, on 30 June the Trust’s medical director sent Charlie’s parents a copy with a letter expressing sincere and heartfelt apologies and condolences and assuring them that the Trust accepted the review conclusions in full and was working hard to address them.
The letter also said, “The key conclusion that stands out to me, and I am sure it will to you also, is that the assessment made of Charlie on 5 September 2019 by the paediatric registrar was not acceptable and that there was a missed opportunity to discuss Charlie’s care in a more urgent manner with the paediatric consultant. The investigation has concluded that had there been a more urgent response, there may have been an opportunity to save Charlie's life.”
Life could have been saved
This position was reiterated on the Trust’s behalf during the current hearing by the consultant paediatrician, who agreed that the paediatric registrar’s assessment was not acceptable and acknowledged that ‘the level of care we normally provide and that Charlie deserved was not provided that night’.
Under questioning by Counsel, the consultant accepted that the registrar failed to recognise the severity of Charlie’s illness as evidenced by blood gases, delaying by several hours emergency surgery that could have saved his life, particularly if he had been taken to theatre before his first cardiac arrest.
The Coroner’s conclusions were: “Charlie had a history of abdominal distension and vomiting. He had several admissions to hospital and underwent extensive examinations and tests. He was admitted to Norfolk and Norwich University Hospital on 5 September 2019 presenting as very unwell and in shock. During late 5 September 2019 Charlie was reviewed from a surgical perspective and the gravity of Charlie’s condition and the need for surgery were not recognised. Surgical advice was not sought from the on-call Consultant.
“Charlie’s condition deteriorated further and it was not until it was re-escalated to the medical team that the need for surgery was recognised. Charlie did not undergo surgery until the early hours of 6 September 2019 when an emergency laparotomy was performed. Charlie’s condition remained serious. Later that day he was transferred to Addenbrooke’s Hospital where his condition continued to deteriorate and he died. Charlie Goodwin died from a rare and undiagnosed bowel malrotation and midgut volvulus.”
Under her Regulation 28 duty, to prevent future deaths, the Coroner has noted that she will be writing to the General Medical Council, inviting them to have a recording of the inquest and will inform them that they may wish to investigate the paediatric surgical registrar’s evidence and his fitness to practice.
Having heard the Inquest outcome, Craig Knightley said, “Had Charlie been assessed properly, it is likely that he would have been taken to surgery much earlier, well before his condition deteriorated further and he suffered from a cardiac arrest. Had that been the case, Charlie’s chances of survival would have been much greater and it is likely that his life would have been saved.”
He went on to add, “Charlie’s mum Nicola and the whole family are desperate to ensure that this never happens to anyone else. They are devastated by the loss of their wonderful, incredibly loving and funny son and brother. They want to raise general and medical awareness of this rare condition and hope to do so in Charlie’s memory.”