Hospitals with the facility to conduct MRI scans under general anaesthetic for children undertake between 1.5 and 7 scans per week, depending on the size and catchment of the trust. The approach to pre-assessment may differ between hospitals, and the provision of additional support for patients with special needs may also vary.
The detection of diseases in patients with autism, a learning difficulty and/or a learning disability is challenging. In the context of an elective anaesthetic, this investigation seeks to establish the extent of the safety risks associated with patients with special needs highlighted in the reference event.
We were notified by a district general hospital of the death of a young patient who had undergone an MRI scan under general anaesthetic to investigate their recurrent headaches.
The patient was being treated for growth hormone deficiency and had autism spectrum disorder and an associated learning difficulty.
During the scan, the patient suffered unexpected deterioration, which was subsequently discovered to have been caused by an undetected heart condition (cardiomyopathy). The patient was stabilised in the hospital intensive care unit and subsequently transferred to the Paediatric Intensive Care Unit at a regional children’s hospital but died three days later.
The reference event highlights potential national safety risks linked to care pathways, human factors, awareness and training regarding patients with autism, learning difficulties and learning disabilities, consent, and clinical practice guidance when undertaking MRI scans under anaesthetic.
Identified safety issues
This investigation is looking at:
- The current evidence base and guidance for anaesthetic pre-assessment clinics, on-day procedures which involve anaesthetics, consent in children, and the considerations for patients with special needs or who require reasonable adjustments to be made.
- The impact that autism, learning disabilities and learning difficulties have on mainstream healthcare service provision in relation to the safety risks identified, and the detection of diseases in patients with special needs.
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