Coroner raises concerns over care of teenager who died at Peterborough City Hospital

A coroner has raised concerns about the training of staff at Peterborough City Hospital following the death of a teenager.

Christian Hobbs, 17, tragically passed away from complications resulting from an undiagnosed heart condition at the hospital on Boxing Day, 2017.

The teenager was an ‘amateur boxer’ and described as incredibly fit by his family.

But on Christmas day in 2017 he began to feel unwell. His mum called his grandfather – a retired consultant surgeon – to come and look at him. He noted concerning features, including Christian being “deathly pale”, “clammy” and “shut down”.

Christian’s grandfather, after assessing him, telephoned the hospital to alert the hospital to his imminent arrival, his heart rate of 240 bpm and his prejudiced cardiac output.

His parents immediately rushed him to the hospital – where he was seen in the emergency department (ED) at 5.42pm, complaining of a tight chest and vomiting. By 7.35pm it was noted the teenager looked “palour” and was “presenting as acutely ill”.

At around 8pm his parents urgently called for help for their son.

CPR followed, and the teenager was intubated.

Despite several further procedures and tests, treatment was stopped with the family’s consent, and Christian was “allowed to die” – with his death recorded at 11.45pm.

A post-mortem examination carried out by coroner David Heming found that Christian had a rare condition which can cause the walls of the heart to weaken.

In his Prevention of Future Deaths Report, Mr Heming writes he “died from complications following an acute deterioration having decompensated over a short period of time on a background of a previously undiagnosed pre-existing arrhythmogenic cardiomyopathy.”

He goes on to raise concerns about the treatment Christian received at the hospital, stating: "I found that the urgency of the situation was under-appreciated by the treating team." He noted there was a delay in getting the first blood gas, adding this “would likely have shown a raised lactate and potassium – both of which would have impacted on management and should have further highlighted the severity of the situation.”

He continued: “During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken.

“Christian had not had an echocardiogram prior to his arrest. This was a concerning feature of his care in the ED given he was critically unwell and in a shocked state.”

Mr Heming did, however, state the care given during the resuscitation “was generally of a high standard and everything possible was done to restore a spontaneous circulation and to protect organs from damage”.

Addressing the North West Anglia NHS Trust (NWAFT) which runs the hospital, Mr Heming went on: “The under appreciation by some staff of how critically unwell Christian was raises an issue on exchanges of information and team culture.”

His report also noted another area of concern within the trust is radiology. “In the case of Christian, nothing is recorded in the notes on assessment of the X-Rays undertaken,” Mr Heming notes. “A recurring theme is lack of a differential diagnosis which raises concerns about training.”

Addressing further issues with the Royal College of Radiology and the Department of Health and Social Care, Mr Heming goes on: “I have a concern over whether there are sufficient numbers of radiologists to cover the ever-increasing expansion of imaging as a key diagnostic tool."

He concluded by calling for action to be taken “to prevent future deaths”.

The organisations involved have until June 2 to respond to the report.

The Peterborough Telegraph approached the NWAFT and ICB for a comment.

A spokesperson for the NWAFT said: “The Regulation 28 Prevention of Future Deaths report has only recently been shared and we’re still within the window to review and respond, therefore it would not be appropriate to provide a comment at this time.”

The ICB added: “As we are in the process of considering and responding to the report, we are not in a position currently to offer comment.”