Coroner rules neglect on hospital ward contributed to death of 'happy, cheery' Corby teen Zak Fairhurst who died after spinal surgery at John Radcliffe Hospital
The sudden death of a Corby teenager who went into John Radcliffe Hospital for a spinal surgery and never came home was contributed to by neglect, a coroner has ruled.
Zak James John Fairhurst, 18, died last February in the Oxford hospital after being moved to an adult ward following his surgery. The court heard how he had been given high doses of morphine and should have been monitored every four hours, but he was not properly checked between 10pm and 6.50am.
Following todays (Tuesday, October 31) inquest into the death of the former Corby Business Academy pupil, Coroner Darren Salter said that Zak could have survived if hourly observations had been carried out by nurses.
He said that neglect contributed to Zak’s death.
The youngster contracted meningitis at 18 months and was left with quadriplegic cerebral palsy, epilepsy, global development delay and scoliosis. He was also fed via a tube into his stomach and was non-verbal but communicated through gestures and sounds.
His family say that despite these conditions Zak lived a very full life, he was a ‘healthy, happy, cheery young boy’ who ‘should have come out of the hospital and continued to live a full life’.
‘Zak made me who I am’
A statement to the inquest from Zak’s mum Vikki Fairhurst described how her son fought off meningitis when he was a toddler. She said: “I had lost the Zak I knew, but I got him back in only the way he knew by giving you beautiful cuddles plenty of kisses and great big belly laughs when you made a fool of yourself. he had a fantastic sense of humour, and his smile would melt everyone he met.
“We went to Disney in Florida twice and he loved all the characters and the attention they gave him; he loved all the shows and fireworks.
“He liked to be out about so he could be involved in the community and many a time people have spoken to Zak, and I didn’t know them, but he did.
“He loved chocolate and cakes. Zak may have been nonverbal, but he had a way to let you know what he wanted or didn’t, if he didn’t want his dinner, he would always have his pudding!
"Yes, Zak was severely disabled, nonverbal and had huge daily challenges, but he had a full life, a loving life. I cannot express enough how Zak changed my life and has made me who I am, and I am so much stronger for it.
“He turned 18 in November 2021 and we had the biggest Tom and Jerry Party, going to the pub and buying his first pint of cider with dad and Uncle John, he was so proud and the smiles and giggles when he got all the attention is ingrained in my mind for ever.
“Zak was and still is our world. His smile and laugh have melted so many hearts but mine is broken now until I meet him again.”
His dad James, who adopted Zak in 2013, said: “He had a big bright smile and a big, brilliant laugh that made your heart melt, this made your day worthwhile. Zak was the best ever person you would meet in your life.”
‘If I had known, I would not have gone to sleep’
The inquest aimed to answer questions over how Zak suffered a cardiac arrest two days after his surgery and after being transferred to an adult ward.
The court heard how his cause of death was given at post mortem as cardiac arrest with acute lung injury and aspiration pneumonia, following spinal surgery for neuromuscular scoliosis, which was necessary because of spastic tetraplegia and epilepsy following pneumococcal meningitis.
Aspiration pneumonia is when food is discovered in the lungs.
Zak, of Staffa Walk, Corby, had had a previously successful spinal surgery in 2019, but the spinal rod had become fractured so it was decided he needed further surgery.
He had previously been cared for on children’s wards and it had been agreed that he would once again be in paediatric high dependency unit and then a children’s ward – if there was a bed available – following his surgery because he was still in full time education.
But after the surgery on February 2, 2022, there was no paediatric bed available for him so he was placed into the adult ICU, and then the following day was stepped to a side room on an adult neuroscience ward so that his mum could stay in the room with him. The ward did not have an ear probe to monitor his oxygen levels – meaning no observations could be done on the night before he died.
He had been very poorly during the operation and had nearly had a cardiac arrest, but mum Vikki said in her statement to the inquest that she had not been made aware of this.
Although Zak had a settled night on the first night after the operation, Vikki stayed with him the following night,
She said if she had known how ill he had been during surgery, she would have stayed awake.
Her statement said: “If I had known how poorly Zak had been during his surgery.. I would not have gone to sleep.”
‘He ran all the way to the hospital to be with me’
Vikki was asked by nurse Shumirai Chirairo to administer Oramorph (a strong opiod painkiller) to her son at about 4.50am on February 4. She did so, and then was again awoken by the same nurse at 6.50am.
She told the inquest: “Shumirai brought the trolley in to do Zak’s observations.
"She then informed me that she had not managed to do any observations on Zak all night, Zak was still lying on his right-hand side at this point.
"She went over to Zak and this is when she found Zak unresponsive and then pressed the emergency button, the next thing the room is full of people and I’m asked to leave to which I said no, then I saw a doctor on Zak doing CPR.
"I was then escorted screaming to a small room, I called my husband and he ran all the way down to the hospital to be with me.”
Although doctors were able to find a pulse after performing four cycles of CPR, Zak died at 7.15pm after his heart was unable to take anymore.
‘Not yet out of the woods’
Paediatric anaesthetist Bianca-Lea Tingle gave evidence to the inquest. In her statement she said that she had warned Zak’s parents that surgery for him would be risky.
She said that during surgery, Zak became critically unwell but recovered enough for the surgery to be completed.
Dr Tingle said that after the operation finished, she explained the gravity of the situation to Zak’s parents. She said: “I explained how Zak’s condition had improved and stabilised over the following hours to the point where I could extubate him but warned that we were not yet ‘out of the woods’.”
The court was also told that Zak was given morphine in line with a plan that had been produced before his surgery, but that this level of morphine may have been too much for Zak, given his very complex needs.
Consultant Neuro Intensivist Dr Mhairi Speirs also gave evidence to the inquest.
She said that the decision to send Zak to a ward had been made jointly with other senior medics and that it was a result of there not being any paediatric high dependency beds available.
She said: “If there had been any doubt (about his recovery) I would have kept him in intensive care but we wanted to have him in a side room so mum could stay overnight.
"We have all found this devastating but I’d still to the same thing tomorrow because I would not have discharged a patient that was unstable.”
‘There was no indication that he would deteriorate’
Neuroscience Advanced Nurse Practitioner Tania Carvalho Dos Reis told the inquest that part of her job was consider whether nurses care could meet Zak’s care on the ward.
She said that she had assessed him as being appropriate to be stepped-down to the neuroscience ward and handed his care over to nurses.
Her statement said: “I had planned for him to receive four hourly observations and to have neuro and spinal observations. In addition, I would expect nursing staff to undertake medication-appropriate observations – this would include checking Zak’s respiratory observations, alertness and pain levels, when he was given morphine.
“When I returned to the unit on my following shift, I was advised that Zak had deteriorated and had returned to ICU. I was shocked when I heard this because Zak had been stable the day before and there was no indication that he would deteriorate.”
‘I don’t know why I didn’t do it’
Staff nurse Shumirai Chirairo was charged with Zak’s care on the night he deteriorated. She was asked by the coroner why she hadn’t done four-hourly observations on Zak and yet continued to give him morphine without checking his respiratory rate.
It is critically important to record the vital signs of patients receiving morphine, in particular those patients with Zak’s complicated medical history.
Cardiovascular observations were taken at 10.11pm but no oxygen saturation was recorded. Zak was found to have an elevated heart rate.
The court was heard that nurses could not get an accurate oxygen sats reading from an adult probe because they believed it was too big for his finger and so nurses had tried to find an paediatric ear probe. They found one, but but it was not compatible with their machinery.
Nurse Chirairo told the court that she could not remember why no more obs had been completed overnight.
"I don’t know why I didn’t do it,” she said.
She was also asked whether she remembered what Zak’s condition was when she had given him Oramorph overnight and she did not answer.
Under questioning from Vikki Fairhurst, Nurse Chirairo was asked why, when she found Zak’s heart rate to be 129 bpm, she had not escalated the situation or begun hourly observations, as was protocol.
She said that she didn’t know why.
‘The care delivered was clearly inadequate’
Professor Richard Beale was asked by the court to provide an independent report into what happened to Zak.
His statement said that he could not specify at what time Zak had collapsed because no observations had been done. He said: “Zak suffered a cardiac arrest and a major aspiration, most likely as a result of the large cumulative doses of morphine he received, and whilst still vulnerable as a result of his major spinal surgery.
“More broadly, the monitoring and care delivered on the neurosurgical ward on the second post-operative night when these events occurred was clearly inadequate, and this was in the context of an organisational failure that resulted in his being discharged to an environment not equipped to meet his extra needs through the lack of a robust post-operative care plan.”
He said that he believed that Zak could have passively regurgitated and aspirated the contents, and because of the anaesthesia he may not have coughed normally.
His statement noted that Zak’s Oramorph dose was ‘substantial’ and higher than the normal adult dose, adding that higher doses may be appropriate for major procedures where a significant degree of post-operative pain is anticipated.
He said Zak was not a typical patient, and should ‘certainly’ have been closely monitored for response and side effects.
Recording a narrative conclusion, Coroner Darren Salter said: “Overnight on February 3-4, three-hourly morphine was administered.
"Zak should have been closely monitored for response and side effects but observations were not adequately undertaken.
"With appropriate care Zak would not have died when he did and his death was therefore contributed to by neglect.”
Oxford University Hospitals admitted that, with appropriate care, Zak would not have died. An action has since been devised and all but one of the thirteen recommendations are already in process.
They include; the development of guidance for ward staff for stepdown care of patients recently discharged from ITU to the neuroscience ward; patients who have demonstrated sensitivity to opioids and required naloxone should have an urgent review of their analgesia prescription; an education package for all staff over transition of care of young adults with learning disabilities; an inspection of oxygen saturation equipment throughout the neuroscience ward; wards should have at least one small sized finger probe that fits the type of monitors used on the ward, the location of which is known by all staff; a safety message sent to all staff to the effect that strong opioids must not be administered to any patient if the appropriate observations have not happened and if equipment to perform these observations is missing or broken then this must be escalated as far as required.