Prevention of Future Deaths Report: Asher Sinclair (4 September 2022)

Summary

On 24 October 2019 coroner Lydia Brown commenced an investigation into the death of Asher William Robert Sinclair, age 3. The investigation concluded at the end of the inquest on 24 January 2022. The conclusion of the inquest was:

His medical cause of death was:

• 1a Hypoxic ischaemic brain injury
• 1b out of hospital cardiac arrest
• 1c displaced tracheal tube (trachael tube dependant)
• II Neonatal enterviral myocarditis and encephalitis (trachael ventilator dependant and cardiac pacemaker).

Asher died on 8th October 2019 in Great Ormond Street hospital when his life support mechanisms were withdrawn.

Content

Coroner's concerns

Asher was entirely dependent upon a complex package of care as a highly vulnerable ventilator dependent child. Evidence at inquest was that on numerous occasions he was not provided with the prescribed 2:1 care.

The care package, despite being described as one of the most complex and most expensive was not appropriately reviewed and there was no mandatory system of quality checks or formal review when there was a significant change in family circumstances. Quarterly reviews were not carried out without explanation.

The primary responsibility fell upon the family members, namely Asher’s parents, who were also responsible for other children in the family and employed as teachers. Concerns raised by the parents were not taken for discussion to case conference or professional’s meetings and essentially not followed up at all, leaving the situation in the house dangerous with an ultimately calamitous outcome.

There was a lack of scrutiny or reconciliation of Asher’s care package, which could have identified gaps that needed to be addressed. Training for the staff involved was unclear to the court and seemingly not in place or inadequate. A high turnover of staff was cited as one of the reasons, but this should have highlighted a need for increased training and scrutiny.

The court was advised that new structures would be in place by July 2022. The production of this report therefore has been delayed to give the opportunity for those systems to be in place and reported to the court.