Judith Ann Pavey

At birth, C.S' had a shunt implanted into the head to relieve pressure from hydrocephalus. Since the implantation, the shunt developed a history of malfunctioning. It is standard practice to be acutely aware of changes in the child's medical condition, because the changes can signal a shunt malfunction, which, if left untreated, can result in brain damage. There was, in this case, both a failure to investigate changes that had been noted over the days leading up to the ER visit, and then once C.S.' condition was bad enough that the mother rushed the child to the emergency room, the staff and the neurosurgical team did not attend to C.S. with the required urgency. By the time the neurosurgeon physically observed C.S. in the ER, the child's condition was so dire that they performed surgery right in the ER. The delay resulted in severe brain damage.