Great Ormond Street: Hospital may have broken law by failing to reveal errors led to boy’s death

NHS hospitals should share information with parents under duty of candour rules says watchdog

Great Ormond Street Hospital has apologised over the death of Walif Yafi (AFP via Getty)

Great Ormond Street Hospital may have broken the law by failing to share information with parents that showed its errors had contributed to their son’s death, The Independent understands.

The care watchdog is speaking to Great Ormond Street about its handling of an expert report into five-year-old Walif Yafi in 2017.

It showed that the hospital’s failure to share results that showed a deadly infection had played a role in Walif’s death. But the boy’s parents were only told about the findings after inquiries by The Independent – months after settling a lawsuit with Great Ormond Street in which the trust denied responsibility.

The Care Quality Commission is looking at concerns relating to duty of candour regulations, which require hospitals to be open and honest with families about mistakes made that result in serious harm to patients. Breaching the regulations is a criminal offence and can lead to prosecution.

The renowned Children’s hospital has apologised to Walif Yafi’s family and offered to meet with them to explain the new findings that came from an expert report commissioned by NHS Resolution, which handles litigation claims for trusts.

The case has wider implications for NHS hospitals after the CQC confirmed all trusts are under a duty of candour when they learn of any new information that materially changes the facts about a serious incident of avoidable harm regardless of when the incident occurred.  

The watchdog also confirmed that the legal process around clinical negligence claims does not alter the requirements on hospitals to be honest with families about mistakes made.  

The Duty of Candour was introduced as part of 12 new fundamental standards of care following the Mid Staffordshire hospital scandal and subsequent public inquiry led by Sir Robert Francis QC which found hundreds of patients had suffered neglect and poor care.

Great Ormond Street has faced criticism over its response to safety incidents in recent weeks after experts accused it of a cover up over the death of toddler Jasmine Hughes after vital clinical information was left out of her medical records and other information went missing or was not shared with a coroner.

Treasury minister Steve Barclay, constituency MP for Jasmine’s parents, has called for an investigation. The hospital was also implicated in poor care of baby Elizabeth Dixon in an inquiry that was published last week.

In both Jasmine Hughes and Elizabeth Dixon, mismanagement of blood pressure led to them suffering permanent brain damage.

In Walif Yafi’s case, he had a liver transplant after treatment for cancer and was being seen as an outpatient by Great Ormond Street in 2017. A blood test showed he had contracted an adenovirus infection but this was not communicated to his doctors at King’s College Hospital.

Walif became unwell and deteriorated over the following weeks and although anti-viral treatments were started he continued to decline before dying in September 2017.

An expert report into the delays by GOSH of sharing the blood tests results concluded the errors “materially contributed to his death”.  

His parents and lawyers were not told about this until contacted by The Independent.

Professor Ted Baker, chief inspector of Hospitals, told The Independent: “We are following up with Great Ormond Street Hospital NHS Foundation Trust with regards to the application of duty of candour in this case.”  

Asked whether the duty of candour would apply in a case where a trust came into possession of new information about an incident the CQC said yes the duty would still apply.

It said hospitals should “provide an account of what happened which covers everything the provider knows” and that it should provide updates on any investigations.

In relation to the litigation process, the CQC said this did not alter the responsibilities on NHS trusts under the duty of candour. It said: “The duty of candour is about apologising and being open about what has happened as the process of investigation takes place. Carrying out the duty, or apologising in itself, does not imply that the provider has accepted liability. NHS Resolution are quite clear about this in their guidance for providers.”

A spokesperson for NHS Resolution added: “We always encourage trusts to be entirely open with families, in line with their duty of candour and irrespective of legal privilege. This is the right thing to do and is the best way to learn from events and improve.”

They said expert comments commissioned as part of a legal process were treated as being privileged but added: “This doesn’t mean that trusts should not share conclusions with families, explain what happened and apologise and we encourage them to do. We have every sympathy for families who feel that this legal process does not serve their needs well.

“This is why we aim to keep as many cases as possible out of formal legal proceedings and offer mediation so that issues can be explored directly and in more depth than the legal process allows.”

A spokesperson for Great Ormond Street Hospital said: “We are very sorry to Walif’s family and have apologised for the delay in communicating the test result. Legal proceedings have recently concluded and we are organising a meeting with Walif’s family to engage with them further about their son’s care, while we have already responded to CQC’s questions about this case and would be happy to address any further queries they may have.”