Challenges of missed and delayed diagnosisIs there anyone who has no experience of this either personally or

through being involved subsequently or both??

A real life case story

Break out groups

What we can do to minimise it, deal with it and share learning

Katie9 months old

Admitted to local hospital with 1 week history of fever, lethargy and increased work of breathing

Initial management• 02• Antibiotics

In patient for 5 days -Increasing lethargy and vomitingDifficult IV access – oral antibioticsCXR unchangedReferred to paediatric respiratory team at tertiary centre

Mum“I was so relieved at that point because I felt like I was watching

her get worse every day – she’s normally such a happy little thing and all she did was lie there. By the end she didn’t even cry when they tried to take some blood from her. But everyone said she would be fine – its just a chest infection ”

Transferred to tertiary centreArrived 4 pm Saturday afternoon to paediatric wardO/A – grunting, responding to pain only. Sao02 88%, RR 50, HR 180,

CRT 3 secondsCapillary blood gas – ph 6.9, BE -14, C02 8, K+ 8.4Immediately transferred to PICUDecision to I+VVT on induction – PEAROSC at 5 minutesOngoing resuscitation – fluids, calcium, bicarbonate2nd arrest – no ROSC and cannulated for ECLS after 30 minutes CPROn ECLS by 5.30 pm – 90 minutes after arrival

Subsequent eventsBloods – confirmed diagnosis of pneumococcal haemolytic uraemic

syndromeSlow respiratory improvementOngoing renal replacement therapyWeaned off ECLS after 5 days but remained very obtundedCT head – extensive infarction with basal ganglia changesEEG – severe encephalopathy

No improvement – parents counselled re likely neurological prognosis and agreed to non escalation of care

Progressive MOF – withdrawal of support

What happened next?

Consultant and nurse involved both went off sickNo RCADecision (that had already been considered prior to this event) to

move in patient paediatric services from that site was expeditedDid we learn from it? No.

What about the parents?“ We let her down. We knew she was desperately sick and we kept

trying to tell people but no one listened. At the end of the day I just keep thinking, there must have been something else I could have done, some way I could have got help for her. And I didn’t and we have to live with that.”

Break out – your turn!!

Challenges of missed and delayed diagnosisWhy? The cognitive psychologyHow can we minimise that? – Cognitive interventions to reduce

diagnostic errorHow do we deal with it?

debriefing2nd victimmoral distressresilience

We’re all in this together