What the Department of Health concluded

The restricted report, examined by the Sentinel, was entitled: “Root Cause Investigation Into the Circumstances Surrounding The Death of Orla O’Kane.”

The investigation set out its remit in three sections:

1: To enquire into the circumstances that led to the delay in communication of the results of tests conducted on the deceased to relevant stakeholders and in particular to the family of the deceased.

2:Having made such enquiries to make recommendations to the Minister in relation to appropriate action by Health and Social Care Services and staff to ensure such circumstances do not occur again.

3:To ensure that the learning from this incident is disseminated.”

The methodology in compiling the report included holding structured discussions involving the relevant stakeholders, establishing a time line of events and identifying contributory and root causes leading to the incident and establishing learning points. The investigating team was led by Chief Medical Officer Michael McBride who was assisted by the Deputy Chief Medical Officer, Dr Elizabeth Mitchell.

In a section of the report called ‘Description of incident and impact’ it is stated: “On Sunday, 11 October, 2009, Orla O’Kane, a 14-year-old girl, died in the Accident and Emergency (A&E) department of Altnagelvin Hospital (WHSCT). The cause of death was bronchial pneumonia, with co-morbid Cerebral Palsy and Asthma.”

The report also states that Orla was tested for swine flu after her death. It continues: “This test was positive, however a delay occurred in communicating the result of the positive H1N1 swine flu test to the healthcare professional who requested the test and other relevant professionals within Health and Social Care organisations, and ultimately therefore to Orla’s family. There were also delays in the follow-up procedures in respect of family members and relevant HSC staff members that had occupational exposure from attempts to resuscitate Orla.

“Whilst there were no direct consequences for the individual’s patient care, the delay caused considerable distress to the family, including concerns about the potential exposure to the infection at the funeral.”

The report notes that the principal of Orla O’Kane’s school, Dr Michael Dobbins of Foyle View had contacted the Public Health Agency (PHA) on Monday, October 12, 2009, to report that she had died and that another pupil had been confirmed as having contracted H1N1.

The decision was then taken to recommend all pupils at the school should be offered antivirals. The report states: “The question has been asked if this had taken place earlier would it have made a difference to the outcome.

“When the other pupil was admitted to hospital (Friday, October 9, 2009) a swab was taken to test for H1N1 swine flu, as one of the possible diagnoses. The laboratory diagnosis was subsequently made and reported to the hospital late on Saturday evening (October 10). Given the level of community transmission of H1N1 swine flu at this time it was not the policy to routinely give prophylaxis (preventative measures, i.e.-swabbing) with antiviral medication to the contacts of a case of H1N1 swine flu infection.

“Therefore there was no reason for the hospital staff to contact the PHA to report individual cases.

“Orla had been unwell since Wednesday 7 October. To be most clinically effective antivirals should have been given within 48 hours of onset of symptoms. It is therefore unlikely that if antivirals had been given to Orla on Sunday, October 11 (the day of her death) that it would have made a difference.”

Yet, the report notes on this point that these future actions should be observed: “It is important that the H1N1 swine flu vaccine, which affords the greatest amount of protection against the virus, continues to be offered to all those in identified high risk groups.

“In the event of the emergence of a new pandemic strain of influenza early consideration should be given to offering prophylaxis to those most at risk of complications from the virus.

“In the event of the emergence of a new pandemic strain of influenza early consideration should be given to offering prophylaxis to those most at risk of complications from the virus.”

In the chronology of events leading to the tragic passing of Orla O’Kane, the report notes: “On Wednesday, 7 October, 2009, Orla’s family contacted their GP to seek an antibiotic for a suspected chest infection, which was subsequently prescribed. Given Orla’s medical history it was usual practice for the GP to prescribe antibiotics with follow-up by the Consultant Paediatrician should the symptoms persist. A few days later, on the evening of Sunday, 11 October, Orla’s parents found her not breathing and immediately called for an ambulance. Despite attempted resuscitation at the scene, during transfer to hospital and in the Accident and Emergency Department of Altnagelvin Hospital, sadly attempts to resuscitate Orla were unsuccessful.”

The final section of the DHSS&PS report called ‘Root causes of the failure of communication’ states: “It is apparent that because Orla died in Altnagelvin Accident & Emergency department and was therefore not admitted as an inpatient, and as the sample taken was post-mortem the normal arrangements for follow-up of clinical samples were not followed.

“In normal circumstances responsibility for acting upon the result of a test rests with the clinician who ordered it. Results of laboratory tests performed locally are made available on-line by the RVL (Regional Virology Laboratory). There is a system in the hospital of alerting clinicians to completed results where they are perceived to be significant. In all cases a written report is returned to the originator, who has responsibility for accurately completing information (Consultant Name, Ward location etc.) on the request form in order to enable this to happen.

“Where the patient is an in-patient the reports are delivered to the ward. Ward staff then check the reports and countersign them.

“They are then filed. If the patient has already been discharged the reports are sent to the Consultant’s secretary. They are then attached to the patient’s case notes and brought to the attention of the responsible clinician.

“Where diagnostic tests are carried out while the patient is in the A&E department, the results are returned to A&E. Those that relate to a patient subsequently admitted are forwarded to the relevant ward. The remainder are checked by A&E staff and filed.

“There was a lack of clarity in the test request form as to where the request had originated and to whom the result should be advised. Taken together with the fact that A&E, Paediatric and Primary Care Liaison colleagues were unaware that the H1N1 swine flu test had been requested and that Laboratory staff later spoke to a non-clinical Trust employee who would not have realised the significance of the test result, the appropriate action was not taken on a timely basis.

“Overall there was a series of communication failures both within and between HSC organisations, and communication with the family suffered as a result.

“There were also delays in the follow-up procedures in respect of HSC staff members that had occupational exposure during attempted resuscitation.”

The recommendations of this report ran as follows: “1 - The Department should issue urgent advice to the HSC for the ordering and follow-up of tests. This should reinforce the need to apply due diligence to tests taken for public health reasons, as well as those taken for clinical diagnosis. 2 - The Department should issue urgent advice to the HSC, funeral directors/undertakers as to best practice information on funeral arrangements of people with H1N1 swine flu. 3 - The Department should issue urgent advice to the HSC highlighting the particular importance of maintaining effective internal, external, and interface communications arrangements, especially in challenging circumstances.”