Luke Jenkins death partly due to 'low staffing' levels
A boy who went into hospital for heart surgery suffered cardiac arrest and died partly due to staff shortages, a report has said.
Luke Jenkins, seven, of Cardiff, was expected to make a recovery after surgery at Bristol Children's Hospital.
A report said he was moved from intensive care 24 hours after the operation because of "increasing demand" on beds in the department.
Later, ward staff did not "fully consider" why bleeding had increased.
The report, put together by an investigative team at University Hospitals Bristol NHS Foundation Trust, said "the workload and patient dependency is recognised as being significant" in Luke's death.
When he collapsed on his ward, junior staff did not know where a vital piece of resuscitation equipment was kept.
The report added the lack of knowledge had "caused a delay" but it was "minor and would not have affected the outcome".
Luke was born with a congenital heart defect and had already had two of three corrective operations before undergoing the third.
Longer stay 'beneficial'
Following Luke's operation he was moved from the paediatric intensive care unit (PICU) on 31 March.
"Due to the demands on PICU capacity, patients are more likely to be discharged from PICU at an earlier post-operative phase," the report said.
It added that a longer stay in PICU would have been "beneficial".
But afterwards, staff on the new ward failed to consider fully what might be causing a significant blood loss and growing chest pain or to respond to his worsening condition.
Luke was frequently triggering alarms on his monitoring equipment and his family witnessed those alarms being reset at a lower threshold by nursing staff
Luke collapsed on 6 April with "minimal cardiac output" and a "large volume of fluid" was found on his right chest.
He suffered cardiac arrest on Good Friday and the duty surgeon was called to operate.
His heart stopped for 43 minutes before he was resuscitated, after which he underwent exploratory surgery.
He died early the next day.
'Unsafe nurse staffing'
The report said a risk assessment which had previously been carried out identified "low and unsafe nurse staffing for a cardiac high dependency unit".
According to the report, there have been eight separate patient safety incidents on the ward since January, two of those sparking "high-risk" investigations, linked to low staffing levels.
Additionally, Luke's parent's repeatedly asked for him to be moved back to the intensive care ward but this did not take place.
Luke's parents, Stephen Jenkins, 30, and wife Faye, 27, of St Mellons, Cardiff, south Wales, said other such incidents should be made public by the trust.
"There have been eight other incidents since January 2012. They cannot tell us who the people were but that should be made public," Mr Jenkins said.
Deborah Lee, acting chief executive for University Hospitals Bristol NHS Foundation Trust, said she extended her "deepest sympathy" to Luke's family and said the incident was "rigorously investigated".
"Incidents do occur in a complex specialty such as paediatric cardiac services where we are caring for some of the sickest children in the region," she said.
"Each incident, no matter how minor it may appear, is recorded, rigorously investigated and actions taken forward as part of our clinical governance process.
"We have a nursing establishment for every ward which is benchmarked against Royal College of Nursing guidance and we review the dependency and number of patients we are caring for on a daily basis."
An inquest at Avon Coroner's Court into Luke's death has been opened and adjourned to a later date.