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A tragic incident at Glasgow’s Royal Hospital for Children resulted in the death of three-year-old Archie Donald, a case that could have been prevented had a critical abnormal blood test been addressed promptly, a sheriff has concluded. Archie passed away on 20 November 2019 due to an infection, sparking a fatal accident inquiry (FAI) held at Glasgow Sheriff Court which examined the circumstances surrounding the recognition and management of his illness, as well as delays in hospital admission and issues with record sharing.
Archie, born on 22 July 2016, was living with congenital nephritic syndrome (CNS), a condition that necessitated ongoing medical care including the removal of his left kidney in 2017. Due to this, he attended regular outpatient appointments and had multiple hospital admissions for various illnesses. In the weeks before his final hospital stay, Archie had been seen twice, but on each occasion, medical staff failed to identify the bacterial endocarditis infection that was ultimately determined to be the cause of his death during a post-mortem investigation.
A key point arising from the inquiry was a blood test taken during a routine outpatient visit on 5 November 2019. This test revealed that Archie’s C-reactive protein (CRP) level—a marker for inflammation and infection—was alarmingly high at 98mg per litre, far above normal limits. Despite this, Archie was not assessed for infection, no blood cultures were collected, and he was sent home. Sheriff Thomas Millar, in his ruling, stated that Archie’s death could have been realistically prevented if appropriate action had been taken in response to this elevated CRP. He also remarked that blood cultures taken at that time “on balance” would likely have detected Enterococcus faecalis, a bacteria capable of causing severe infection once it spreads beyond the intestines, which would have led to timely investigations and antibiotic treatment.
The inquiry also highlighted failures in adhering to established clinical guidelines and Archie’s specific anticipatory care plan, which would have included consultation with infectious disease specialists. Moreover, it was noted that elevated CRP readings were recorded frequently between early October and the November appointment but were not consistently documented, including the notable result on 5 November which was missing from his discharge summary. A scheduled multidisciplinary team review where these findings should have been addressed was postponed. When Archie returned on 19 November, he was observed to be very pale with a new heart murmur, prompting further tests, admission for a blood transfusion, and administration of antibiotics. Unfortunately, his condition deteriorated rapidly, and despite resuscitation attempts after he stopped breathing, Archie died early that morning. Samples later confirmed the presence of Enterococcus faecalis in his intravenous line.
Sheriff Millar expressed sympathy for Archie’s family, recognizing the difficulties they endured by participating in the inquiry and praising their devoted care since his birth. He reflected on the tragic timing, noting that Archie was preparing to undergo a kidney transplant with a donation arranged from his father. Following the release of the inquiry’s findings, Procurator Fiscal Andy Shanks emphasized the thoroughness of the investigation and acknowledged that the death had caused significant public concern. NHS Greater Glasgow and Clyde extended their condolences to Archie’s family and welcomed the sheriff’s conclusions, confirming that necessary changes had been implemented since the incident and that no further recommendations were made
Read the full article from The BBC here: Read More
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