Viviana-Ray Butnaru: Prevention of future deaths report 

The Associate Director of Nursing for Paediatrics at Mid & South Essex NHS Trust  stated that the Children’s Early Warning Tool (“CEWT”) Red score was not escalated in  accordance with trust policy. No blood pressure readings were ever taken of Viviana-Ray, and it was stated that all children presenting to the Paediatric Emergency  Department should be reviewed using the PIER Sepsis Tool during triage which was not completed for Viviana-Ray. The Trust also stated that when Viviana-Ray had an Amber  score with two triggers which requires a review by the Nurse in Charge (NIC) and a  Paediatric Registrar within 20 minutes, that this was also not complied with.  

Aside from the initial observation, no other observations or nursing documentation was completed during Viviana-Ray’s attendance at the Paediatric Emergency Department. 

Whilst a review took place at 10:15 am on 25 October 2024 by the Paediatric 
Consultant, no further review appears to have taken place until 16:00 later that day. The Paediatric Consultant stated that clinically Viviana-Ray looked like she was improving despite Viviana-Ray’s blood gas levels showing she was in metabolic acidosis. A repeat blood gas was not performed as the Paediatric Consultant attributed any decline in  these results to be associated with her bronchiolitis and suspected sepsis and no other  underlying cause for the metabolic acidosis was explored.   

The Paediatric Consultant had not noticed an enlarged heart on Viviana-Ray’s chest X ray and stated that it was normal for children to often have slightly larger hearts on X  rays due to the angles in which these are taken.  The Paediatric Consultant stated that staff had not made her aware of any further concerns during the remainder of her shift  except until 4 pm when a nurse notified her that Viviana-Ray was working harder with  her breathing. 
During the inquest another Paediatric Consultant giving expert evidence (and involved in the Patient Safety Incident Report) stated that she found that there were features of mild  to possibly moderate cardiomegaly (enlarged heart) on both chest X-rays. The Paediatric Consultant stated that it would be difficult to definitively determine whether the missed identification of cardiomegaly would have led to a cardiac arrest, but that earlier  detection and intervention, including additional investigations and consultation with a  tertiary Paediatric Cardiology centre, might have provided further insights and possibly  informed management decisions.   

The Associate Director of Nursing for Paediatrics stated that based on Viviana-Ray’s physiological parameters and CEWT score, earlier medical reviews would have been beneficial considering her clinical trajectory.   
Viviana-Ray’s breathing was worsening, and her condition began to deteriorate around 9 pm on 25 October 2024 and it was at this time when it was first suspected that Viviana- Ray was experiencing heart failure.   
Arrangements were made for urgent intubation.  A crash call was put out for the  anaesthetic team.  Viviana-Ray had lost her pulse, and pulseless electrical activity was confirmed at 21:46.  Viviana-Ray was intubated and Cardiopulmonary Resuscitation  continued following the Non-shockable Pathway.  Viviana-Ray had CPR for 51 minutes but was sadly declared deceased at 22:37 at Basildon Hospital. The cause of death is  myocarditis caused by the Parvovirus, contributed to by a background of bronchiolitis  and bronchopneumonia.    

Expert evidence in this case noted that by the time the heart failure was clinically obvious there would not have been an opportunity to reverse the situation as Viviana- Ray arrested shortly afterwards. The expert went on to say that Parvovirus was the likely cause of the myocarditis and that Acute Fulminant Myocarditis is characterised by  the rapid onset of severe heart failure and cardiogenic shock, requiring advanced  pharmacological or mechanical circulatory support.  The expert also stated that there 
has been a recent surge in Parvovirus amongst children following the Covid pandemic. It was stated that diagnosing this remains challenging and that it would be helpful for  paediatricians to have guidance on how to identify such cases.   

The MATTERS OF CONCERN are as follows.    
National Concerns:  
(1)  There appears to be a lack of local or national guidelines assisting those  assessing patients in an accident and emergency and paediatric environment to assess the correct pathway for identifying and investigating those who may  present with heart related issues such as myocarditis.  
(2)  Raising awareness of the existence of Parvovirus considering the surge of this virus in children post the Covid 19 pandemic. 

Local Concerns:  
(3)  Chest X rays which showed cardiomegaly were not reported officially by a radiologist until several days later.  
(4)  Underlying causes for metabolic acidosis were not fully explored. Greater awareness of the difference between metabolic and respiratory acidosis is  required.  
(5)  Incomplete documentation to be addressed to include all updates from nursing staff in relation to observations and escalations; and handovers from the  medical team to one another to be clearly recorded. 

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