Lack of teamwork contributed to the death of little girl.
Coco Bradford, six years old, was admitted to the emergency department of the Royal Cornwall Hospital at Treliske on July 25th, 2017, with a variety of symptoms. She was discharged home but taken back to Treliske the following day and admitted to the paediatric ward. On July 28th she was transferred to the adult Intensive Care Unit and then transferred to Bristol Royal Hospital for Children for paediatric intensive care. Tragically, she didn’t respond to treatment, and she died there on July 31st.
An independent investigation into Coco’s death was carried out by healthcare consultants Facere Melius. They documented the events that had taken place and identified a number of missed opportunities which might have averted this outcome. They made a number of recommendations urging the Hospitals Trust to ‘review', ‘consider’ and 'ensure’. But they said nothing at all about how these recommendations should be acted on - in particular, about organizational changes that were needed.
A new report by Dr Peter Levin (formerly of the Department of Social Policy at the London School of Economics and now working with West Cornwall HealthWatch) aims to fill this gap. By applying teamwork analysis to the information provided in the investigation report, it shows how failures in organization, communication and the culture of the paediatric department contributed to Coco’s death. It makes a number of practical, down to earth suggestions for eliminating such failures in future.
Read the detailed executive summary by Dr Peter Levin. Also included under references is the results of the full independent investigation.