Luke Jackson

“The Trust has taken action to address the conclusions of its Root Cause Analysis and has learned and disseminated lessons, improving its processes. This Report is made to assist learning in the public interest as evidence was heard from a consultant from a specialist children's hospital that total body potassium depletion is not always recognised in children with myopathies who become unwell. They may present with diarrhoea and vomiting due to shunting of the blood away from the gut to protect”

“Children with Myopathies - have low muscle mass that compromises their ability to correct their own potassium levels when unwell”

“[the deceased] had a chest infection, however his low potassium made him weaker and as it progressed, he was shunting blood away from his gut to compensate (this assists to protect the vital organs such as the heart and brain) which resulted in loose stools and vomiting; this was not a consequence of gastroenteritis”

“A bolus of potassium and fluid resuscitation to treat gastroenteritis was not sufficient to treat total body potassium depletion which requires a central line with significant potassium replacement in intensive care to manage clinical risk”

“Development of a chest infection requires a child to breath harder and this becomes more difficult in a child with myopathies that is already weakened due to low potassium and will not present with the usual symptoms of respiratory distress”

“As [the deceased] was treated with oxygen therapy, the monitor alarm set for oxygen saturations did not sound as his oxygen did not deplete and he went into cardiac arrest”