The parents of a seven-year-old boy who died following heart surgery have been told Bank Holiday staff shortages at an NHS hospital were partly to blame.
Luke Jenkins, from St Mellons in Cardiff, died in hospital on Good Friday after suffering cardiac arrest.
Luke, who was born with a congenital heart defect, had undergone successful corrective heart surgery at Bristol Children's Hospital.
He was expected to make a full recovery, but he died within a week.
An investigation by University Hospitals Bristol NHS Foundation Trust classified the incident as 'catastrophic' and found a catalogue of avoidable errors contributed to Luke's death, along with clinical patient factors.
The report identified there to be 'low and unsafe nurse staffing' for a cardiac high dependency unit.
'Limited team-work and communication' and 'failure to recognise and monitor deterioration' were also highlighted in the report, which additionally found that staff were confused about who to call in the initial stages of the emergency.
One paragraph of the report reads: 'It was suggested that some members of the junior nursing and medical team were unaware of the fact that there was a chest opening pack on the resuscitation trolley... this lack of knowledge contributed to a delay in the opening of the chest'.
It went on to say the delay was 'minor' and 'would not have affected the outcome for the patient'.
But it did find that the team were 'not familiar' with how to use the piece of equipment because cardiac arrest was rare in the ward situation.
Luke's parents Stephen Jenkins, 30, and wife Faye, 27, say they're still fighting for answers.
– Stephen Jenkins, Luke's father
If Luke had got the care he needed, he would still be here today. We're fighting this for him, we want answers and we want to raise awareness. What about the children who are there now? They weren't giving him enough care - they weren't giving him enough pain relief. It was meant to be high-dependency unit but it wasn't - there was one nurse to every eight patients and they wouldn't see him for up to 12 hours.
Deborah Lee, the Acting Chief Executive for University Hospitals Bristol NHS Foundation Trust, has released a statement expressing sympathy for the family, and outlining some of the complexities in the case.
– Deborah Lee, Acting Chief Executive for University Hospitals Bristol NHS Foundation Trust
“We extend our deepest sympathy to the family for the loss of their child. We are aware of their concerns about the care that their child received and are investigating those concerns. We are in contact with the family.
Incidents do occur in a complex specialty such as paediatric cardiac services, where we are caring for some of the sickest children in the region. Each incident, no matter how minor it may appear, is recorded, rigorously investigated and actions taken forward as part of our clinical governance process.
We provide highly specialist care for children with a range of complex cardiac problems from South Wales and the South West and our reported cardiac outcomes are amongst the best in the UK. Nevertheless, it is vital that we continually assure ourselves of the quality of care we provide and ensure that children are cared for in the correct hospital environment.
We have a nursing establishment for every ward which is benchmarked against Royal College of Nursing guidance and we review the dependency and number of patients we are caring for on a daily basis. We will call additional staff if this is required and our 24/7 high dependency outreach nurses are very skilled.
As is standard practice in all Paediatric Cardiac Units, out of hours and on Bank Holidays we always have a consultant surgeon and a specialist registrar in cardiac surgery available on call, as well as a consultant cardiologist and specialist registrar in cardiology on call. This means that they must be available to come in at all times. The cardiac surgeon responded and was working on the child within 19 minutes of receiving the call.
The report has now been passed on to the Bristol coroner, and an inquest is due to be held.