Barking and Dagenham Child Death Overview Panel

Annual Report 2012-2013

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Contents

Introduction…………………………………………………………………………….. 3

Terms of Reference

Organisation and resourcing of Child Death Overview Panel ………………. 3

North East London (seven borough) Child Death Overview Panel Meetings 3

The Coronial Service ……………………………………………………………… 4

Core membership ………………………………………………………………… 4

Definition of child death categories ….…………………………………………. 5

Demographic Profile …………………………………………………………………. 5

Overview of notified cases…………………………………………………………… 6

Number of deaths in Barking and Dagenham ………………………………… 6

Child deaths received by quarter ………………………………………………… 6

Unexpected deaths ……………………………………………………………….. 7

Breakdown according to age……………………………………………………… 7

Ethnicity Breakdown……………………………………………………………..... 8

Sudden Unexpected Deaths in Infancy (SUDI) ……………………………..... 8

Commentary of cases reviewed ……………………...............................…………. 8

Number of meetings held ………………………………………………………... 8

Number of reviews completed …………………………………………………... 9

Neonatal deaths …………………………………………………………………… 10

Sudden Unexpected Deaths in Infancy …………………………………………. 10

Unexpected deaths ………………………………………………………………… 11

Expected deaths ………………………………………………………………...…. 11

Time between the child’s death and completing the review ………………...…. 11

Modifiable Factors and Recommendations…………………………………….......... 12

Actions taken following the reviews of child deaths ..……………………………..... 12

Achievements 2011-12 …………………………………………………………..…… 13

Future work 2012-13 …………………………………………………………………... 14

Appendix 1 – Modifiable Factors to child death reviews 2012-13 .………………... 15

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1. Introduction to Child Death Overview Panel

1.1. Terms of Reference

Through a comprehensive and multi agency review of child deaths, the Child Death Overview Panel (CDOP) aims to understand how and why children die in Barking and Dagenham and use the findings to take action to reduce the risks of future child deaths and to improve the health and safety of the children in the area.

Regulation 6 of the Local Safeguarding Children Boards Regulations 2006, set out the function of the Local Safeguarding Children Board (LSCB) in relation to child deaths, made under section 14(2) of the Children Act 2004. The LSCB is responsible for:

a. collecting and analysing information about each death with a view to identifying—

(i) any case giving rise to the need for a review mentioned in regulation 5(1)(e);

(ii) any matters of concern affecting the safety and welfare of children in the area of the authority;

(iii) any wider public health or safety concerns arising from a particular death or from a pattern of deaths in that area; and

b. establishing procedures for ensuring that there is a coordinated response by the authority, their Board partners and other relevant persons to an unexpected death.

Barking and Dagenham CDOP is asked to categorise the likely cause of death, recorded the event that caused the death and any modifiable factors.1

1.2. Organisation and resourcing of CDOP

As of April 2013, the management of the CDOP Manager transitioned from the NHS to the Council and is jointly funded by the NHS Barking and Dagenham Clinical Commissioning Group (NHSBD CCG) and London Borough of Barking and Dagenham (LBBD).

1.3 North East London (seven borough) CDOP Meetings

Barking and Dagenham is a member of the seven borough north east London CDOP meeting that has been developed to share learning, agree a minimum data set so statistical analysis of trends, emerging themes and common modifiable factors can be better understood and share and learn from actions undertaken in response to emerging themes and modifiable factors. The seven boroughs consist of Barking and Dagenham, Havering, Redbridge, Waltham Forest, Hackney and the City, Newham and Tower Hamlets.

1 Modifiable factors – is where there are factors which may have contributed to the death. These factors are defined as those which, by means of nationally or locally achievable interventions, could be modified to reduce the risk of future child deaths.

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1.4 The Coronial Service

Barking and Dagenham is working closely with Waltham Forest Coroner’s Court to better develop the process to obtain full post mortems so that reviews are thorough and timely.

On 25 July 2013, a new code of standards2 was issued aimed at speeding up inquests into deaths. It is anticipated that most inquests in England and Wales will be completed within six months. This follows complaints that bereaved families have had to wait years for a hearing.

1.5 Core Membership

The position of chair has been taken over by Matthew Cole, Joint Director of Public Health.

We have also welcomed Sue Newton, Designated Nurse Safeguarding and Dr Mahima Ruprasinghe, as Interim Designated Paediatrician for child deaths.

The full membership is made up of:

Matthew Cole Joint Director of Public Health and CDOP Chair

Roselyn Blackman CDOP Manager, LBBD

Dr Mahima Rupasinghe Interim Designated Paediatrician for Unexpected Deaths in Childhood, NHSBD

Sue Newton Designated Nurse Safeguarding, NHSBD CCG

Avraamis Avraam Group Manager for Safeguarding, Quality and Reviews representing Barking and Dagenham Safeguarding Children’s Board

Chris Martin Divisional Director for Complex Needs and Social Care, Children’s Directorate, LBBD

Kevin Jeffery Detective Inspector, Child Abuse Investigation Team, Metropolitan Police Service

Claire Butler Children’s Safeguarding Barking Havering Redbidge Univerisity Hospitals NHS Trust

Dr Junaid Solebo Consultant Paediatrician Named Doctor for Safeguarding Children & Young Adults. Barking Havering Redbridge University Hospitals NHS Trust

Dr Richard Burack Named GP NHSBD

2 https://www.gov.uk/government/news/major-overhaul-of-coroner-services-in-england-and-wales4

Other members are co-opted as and when necessary, to provide expert opinion and to contribute to the discussion of certain deaths.

1.6 Definitions of child death categories

The following definitions are the areas CDOP will provide commentary on reviewed cases in this report.

o Neonatal death - is a death of a live born infant within the first 28 days of life.

o Sudden Unexpected Death in Infancy (SUDI) – is marked by the sudden death of an infant, under 2 years old. The death is unexpected by history and remains unexplained after a thorough forensic autopsy and detailed death scene investigation.

Sudden unexpected, unexplained death – where the pathological diagnosis is either SIDS or ‘unascertained’ at any age.

o Unexpected Death - is a death of an infant or child (less than 18 years old) which:

Was not anticipated as a significant possibility for example, 24 hours before the death; or

Where there was a similarly unexpected collapse or incident leading to or precipitating the events which led to the death.3, 4

o Expected Death - an expected death is defined as one where the patient's demise is anticipated in the near future and plans have been put in place and the cause of death is known. There are no suspicious circumstances to suggest that anything untoward has occurred and the decision that death is expected will be clearly documented in clinical notes. This will be separate from a "do not resuscitate order".

2 Demographic Profile

In the 2011 Census, the population of Barking and Dagenham was recorded as 185,911, with a total of 53,544 children aged 0-18 years. This represents 28.8% of the population. Table 1 on the next page gives a breakdown of the total children and shows the number and percentage increase according to age.

3 PJ. Fleming, P.S. Blair, C. Bacon, and P.J. Berry (2000) Sudden Unexpected Death in Infancy. The CESDI SUDI Studies 1993-1996. The Stationary Office. London. ISBN 0 11 3222 9988.4 Royal College of Pathologists and the Royal College of Paediatrics and Child Health (2004) Sudden unexpected death in infancy. A multi-agency protocol for care and investigation. The Report of a working group convened by the Royal College of Pathologists and the Royal College of Paediatrics and Child Health. Royal College of Pathologists and the Royal College of Paediatrics and Child Health, London. www.rcpath.org.

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There has been a significant percentage increase of 48.91% in 0-4 year olds.Table 1

Total number of children by age and increase by number and percentage

2011 2001 Number increase/ decrease

% increase / decrease

All People 185,911 163,944 21,967 13.40%0-4 18,676 12,542 6,134 48.91%5-7 8,989 7,479 1,510 20.19%8-9 5,342 4,984 358 7.18%10-14 12,757 11,107 1,650 14.86%15 2,534 2,242 292 13.02%16-17 5,246 4,441 805 18.13%

The ethnic mix has changed since the 2001 census. The White British group fell from 82.5% of the total population to 50.5%, compared to increases in Black African (from 4.4% to 15.4%) and White other groups (from 2.6% to 7.8%). Asian and other ethnic groups are now estimated at 17.5%, compared to 6% in 2001.5

3. Overview of Notified Cases

Deaths that have been notified to the Barking and Dagenham CDOP are not all reviewed and closed during the same year of notification. The Department of Education recognise it may take a number of months (or years in some cases) to gather sufficient information to be able to fully review a child’s death. This can be due to criminal proceedings, autopsies, coroners’ reports, serious incidents (SIs) and serious case reviews (SCRs). Barking and Dagenham CDOP will await the conclusion of these investigations before a review is undertaken.

Table 2 2008-09 2009-10 2010-11 2011-12 2012-13BD 32 24 19 27 243.1 Number of deaths in Barking and Dagenham notified to the CDOP

In 2012-13, there were 24 child deaths reported to the CDOP. Table 2 gives a breakdown of child deaths reported to the CDOP since its establishment in 2008. This figure has fluctuated between 19 and 32 during the past five years.

3.2 Child death notifications received by quarter

Table 3 below shows this year is the first time since the establishment of CDOP we have seen a high number of deaths over Q2 and 3. In previous years Q3 has returned the highest number of child deaths.

5 http://www.lbbd.gov.uk/CouncilandDemocracy/Census/Documents/130122%20LBBD%202011%20Census%20Key%20Statistics%20FINAL_update.pdf

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Table 3 2008-09 2009-10 2010-11 2011-12 2012-13Q1 4 (13%) 6 (25%) 3 (16%) 7 (26%) 4Q2 8 (25%) 3 (12%) 5 (26%) 5 (18.5%) 8Q3 11 (34%) 10 (42%) 6 (32%) 10 (37%) 8Q4 9 (28%) 5 (21%) 5 (26%) 5 (18.5%) 4Total no of child deaths 32 (100%) 24 (100%) 19 (100%)

27(100%)

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3.3 Unexpected deaths

Of the 24 deaths reported to CDOP this year, there were 9 unexpected deaths. Eight rapid response meetings were held and a rapid response discussion to the one where CDOP did not hold a meeting.

3.4 Breakdown according to age.

Diagram 1 shows the breakdown of child deaths according to age of child deaths reported to CDOP during 2012-13.

The highest proportion of deaths, 46% (11), is within the neonatal period, 0-27 days. Children under 1 year of age represent 67% (16) of the total child deaths. This is consistent with previous years and with national figures.

Diagram 1

46%(11)

21%(5)

4%(1)

17%(4)

8%(2)

4%(1)

Breakdown of child deaths according to age

0-2728-264 days1-4 years old5-9 years old10-14 years old15-18 years old

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3.5 Ethnicity Breakdown

Diagram 2 shows a breakdown of child deaths reported to CDOP in 2012-13 according to ethnicity. 46% (11) of deaths were among the Black African/Caribbean/ Black British group of the resident population.

During 2013-14, the Public Health Directorate will assist the CDOP with statistical analysis of the local neonatal, infant and child mortality rates, using comparative and statistically reliable methods. This will enable the borough to gain a better understanding of any factors such as age, sex, ethnicity or location. This information will be included in the Joint Strategic Needs Assessment (JSNA) and refreshed annually.

Diagram 2

34%(8)

4%(1)

8%(2)

46%(11)

8%(2)

Breakdown of child deaths according to Eth-nicity

White BritishMixed Ethnic GroupsAsian or Asian BritishBlack / African / Car-ibbean/ Black BritishOther ethnic Groups

3.6 Sudden Unexpected Deaths in Infancy (SUDI)

Of the 24 deaths reported to CDOP this year, one involved Project Indigo the Metropolitan Police Service response to SUDI. Whilst the cause of death retuned by the Coroner is SUDI, the panel has not yet reviewed it to formally categorise it. See Point 6 below for further details.

4 Commentary on cases reviewed

This section will provide commentary on the cases reviewed and where modifiable factors have been identified.

4.1 Number of meetings held

CDOP developed a Pre Review Group (PRG) meeting to look at all the cases, before they are presented to the CDOP. The case is discussed and the meeting determine whether there is sufficient information; propose a category of death and consider any modifiable factors.

During 2012-13 CDOP met six times. The PRG also met in excess of six times to fully consider the cases and any potential concerns. These increased number of meetings were paramount to reviewing 46 cases that included six cases from 2010-11 and 27 cases from 2011-12.

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At 31 March 2013, there were 10 child death reviews that were ongoing.

4.2 Number of reviews completed

46 child death reviews were completed by CDOP in 2012-13. This is significantly higher than the reviews completed in previous years.

Table 4 gives a breakdown of the child deaths that were reviewed and the year the child died. Table 4

Number of child deaths that occurred between 1 April 2010-11

Number of child deaths that occurred between 1 April 2011-12

Number of child deaths that occurred between 1 April 2012-13

6 27 13

Of the 46 child death reviews completed, 18 were identified as having modifiable factors.

CDOP categorised the likely cause of death and recorded the event that caused the death.

Table 5 below shows the highest number of deaths was among the perinatal/neonatal event with 11 (24%). These deaths were largely due to prematurity with 6 identified as having modifiable factors. 8 (17%) were among the trauma and other external factors. These included Road Traffic Accidents, Fire and Choking. The three where insufficient information has been categorised, these were due to deaths that occurred abroad. 8(17%) were among the chromosomal, genetic and congenital anomalies and no modifiable factors were identified.

Table 5

 

Number of child deaths with

modifiable factors recorded under this category of

deaths

Number of child deaths with no

modifiable factors recorded under this category of

deaths

Number of child deaths where there

was insufficient information to assess if there were modifiable

factorsTrauma and other external factors 3 2 3Malignancy   6  Acute medical or surgical condition 3    Chronic medical condition   1  Chromosomal, genetic and congenital anomalies   8  Perinatal/neonatal event 6 5  Infection 3 2  Sudden unexpected, unexplained death 3 1  Unknown category      TOTAL 18 25 3

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Table 6 shows a breakdown of the child deaths identified as having modifiable factors and the year the child died.

Table 6

Number of child deaths with modifiable factors that occurred between 1 April 2010-11

Number of child deaths with modifiable factors that occurred between 1 April 2011-12

Number of child deaths with modifiable factors that occurred between 1 April 2012-13

5 11 2

Tables 7 and 8 show the categorisation of deaths where modifiable factors have been identified and the event that caused the death.Table 7

Category

Number of child deaths with modifiable factors

recorded under this category of deaths

Trauma and other external factors 3Acute medical or surgical condition 3Perinatal/neonatal event 6Infection 3Sudden unexpected, unexplained death 3TOTAL 18

Table 8

Events

Number of child deaths with modifiable factors

recorded under this event

Neonatal death 6Sudden unexpected death in infancy 3Road traffic accident/collision 2Fire and burns 1Infection 3Acute Bronchitis 1Epilepsy 1Sickle Cell Crisis 1TOTAL 18

4.3 Neonatal Deaths

There were six neonatal deaths, where modifiable factors were identified (see tables 7 and 8 above). These deaths were classified as expected deaths however three Serious Incident (SI) Reports were completed by Barking, Havering and Redbridge University Hospitals NHS Trust (BHRUT). The SIs are monitored by NHSBD through their Clinical, Quality Review Meeting.

4.4 Sudden Unexpected Death in Infancy (SUDIs)

There were four SUDIs reviewed by CDOP. Three were identified as having modifiable factors. The issues identified were inappropriate feeding in a car seat by the road side;

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no follow-up care plan for child with significant haemolytic disease with attending risk of anaemia and prolonged jaundice; anti-viral treatment should have commenced earlier as precautionary to herpes simplex.

4.5 Unexpected deaths

Of the 46 child death reviews, 20 (43%) were classified as unexpected deaths.

Table 9 gives a breakdown of the unexpected deaths according to the events classified by CDOP. 12 were identified as having modifiable factors.

Table 9

 

Unexpected Deaths

Number of child deaths with modifiable factors recorded under this event

Number of child deaths with no modifiable factors recorded under this event

Number of child deaths where there was insufficient information to assess if there were modifiable factors

Known life limiting condition 1Sudden unexpected death in infancy 3 1Road traffic accident/collision 2 1 1Fire and burns 1 2Other non-intentional injury/accident/trauma 1infection 3Epilepsy 1Sickle Cell Crisis 1Acute Bronchitis 1TOTAL

4.6 Expected Deaths

Of the 46 reviews carried out, 26 related to expected deaths. 18 of these were to under 1 year olds with the majority classified as perinatal/neonatal deaths.

4.7 Time between the child’s death and completing the review

Table 10 below provides a breakdown of the child death reviews according to modifiable factors and number of months.

Data analysed by Department for Education (DfE) suggests that reviews of child deaths are likely to take longer if modifiable factors are identified. DfE says that nearly 40% of deaths where modifiable factors were identified took more than 12 months to complete.6

6 Department for Education Statistical Release 31 March 2013, page 7, para 711

Table 10

Number of child deaths which were reviewed within the following time periods (from the date of death to the date the

review was completed) Number of child

deaths with modifiable factors

Number of child deaths with no

modifiable factors

Number of child deaths where there

was insufficient information to assess if there were modifiable

factorsUnder 6 months 9 16 or 7 months 1 38 or 9 months 2 210 or 11 months 4 4 212 months 1Over one year 11 6UnknownTOTAL 18 25 3

5 Modifiable Factors and Recommendations to all cases reviewed between 2012-13

The modifiable factors identified relate to both unexpected and expected deaths with the majority to unexpected deaths. Recommendations were made by CDOP some arising from SIs and internal investigations. See Appendix 1 for details.

6 Actions taken following the reviews of child deaths

In 2012-13, as well as recommendations made to agencies, CDOP worked with Children's Rights, Participation & Engagement to raise awareness of fire and road safety during child safety week. CDOP also worked jointly on the safe sleep campaign to SUDIs with Havering, Redbridge and Waltham Forest.

Project Indigo’s Draft SUDI – Analytical Report 20137 states that Barking and Dagenham is among the priority boroughs as BD contribute to 48% of all SUDIs in London since 2005. In the East region, 61% of SUDIs occur in Barking and Dagenham, Hackney and Newham combined.

Table 11 on the next page gives a breakdown of SUDIs in BD from 2005 to 20128. The figures show on average two SUDIs a year. The SUDI recorded in 2012 has not yet been reviewed by the Panel.

7 Project Indigo’s Draft SUDI – Analytical Report 2013 has not yet received final sign off8 These figures are recorded as per calendar year

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Table 11

SUDIs from 2005-2012  SUDI

2005 22006 42007 22008  2009 42010  2011 42012 1Total 17

Safe sleeping (including co-sleeping) continue to be a concern to panels, according to DfE9. Other areas of concern are: language barriers and access to health services especially emergency services; consanguinity, bereavement support to include support offered to children following the death of a parent, carer or sibling; smoking and road safety.

The majority of these concerns are being discussed by the north east London seven borough CDOP. Redbridge and Waltham Forest have carried out some work relating to consanguinity. Although, this is not currently an identified theme in BD, Redbridge and Waltham Forest will share their findings with us at the next seven borough meeting in September 2013.

7 Achievements

Developing the effectiveness and quality of the work of CDOP by increasing the number of regular meetings and to include a Development Day within the yearly planner.

Reviewing and closing a high number of open cases.

Revising the Terms of Reference to incorporate the roles and responsibilities of all panel members

Working collaboratively with the 7 borough CDOPs within north east London to share best practices and learning.

Involving bereaved parents and family members into the CDOP process by inviting them to contribute to the process.

9 Department for Education, Statistical Release, page 9, para 513

8 Future Work Plan 2013-14

To consider how to develop the involvement of bereaved parents and family members to the CDOP process.

To develop the recording of bereavement support offered to parents and family members.

Work closely with the Public Health Directorate to identify areas to gain a better understanding of any factors such as age, sex, ethnicity or location.

Develop the sharing of appropriate recommendations and learning to improve practice and develop the effectiveness of CDOP.

Coroners have recently decided not to share Post Mortem reports with CDOPs without the consent of parents. So that deaths can be reviewed thoroughly, CDOP will be incorporating the request for consent within the initial letter that is sent to families.

Identify joint training between Barking and Dagenham, Havering and Redbridge as well as possible further development across the 7 boroughs of North east London.

Develop the CDOP process following the publication of Working Together 2013

Further develop the process following recommendations of CDOP

Further develop actions in response to emerging themes and modifiable factors

Report prepared by:Roselyn Blackman

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CDOP ManagerAppendix 1 – Modifiable Factors / Recommendations to child death reviews 2012-13

All SIs are monitored by NHSBD through their Clinical, Quality Review Meeting.

Un/expectedClassification

Modifiable Factors / Recommendations

UN Road safety and the importance of parents being informed of road safety in relation to young children

UN Recommendations from BHRUT SITrust-wide observation competencies to include assessment of pain.

To ensure that all patients waiting for treatment in majors are clearly visible.

To ensure all Trust policies are adhered to, especially in Sickle Cell and sepsis management.

Revaluate present pathway for 16-year-old adolescents with Sickle Cell disease attending A&E.

To identify one specific monitor that is fully functional and can be used during a resuscitation call on the ward.

To reduce the moves within the Trust, and conversely the number of handovers, an adolescent unit could provide.

Specific care to patients who have complex medical needs.

UN Clinical Assessment Treatment Services (CATS) to run consultant only / nursing staff training (1/2 or full day) & develop a rolling programme and re enact scenarios from A&E and ward.

Improved provision of paediatric anaesthetists.

Employment of Paediatric Advanced Nurse Practitioners.

All paediatric staff to have Advanced Paediatric Life Support training

Improved High Dependency Unit provision for children at Queen’s Hospital

CATS to be contacted for support & advice earlier & to receive appropriate information

UN Recommendations from BHRUT SIFeeding children with respiratory distress: It is important that a written guideline is put in place re: indication of withholding oral

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Un/expectedClassification

Modifiable Factors / Recommendations

feed in children with respiratory distress. The guideline need to be explicit about the volume and frequency of feed, route of feed and when to recommence oral feed. It should also include a checklist to ensure proper placement of nasogastric tube once it is inserted.

There is a need to develop a guideline re: indication of commencing nasal continuous positive airway pressure (CPAP) in young children with respiratory distress. This should include exclusion criteria as well

It is a good practice to inform anaesthetic team at the beginning of commencing any non invasive ventilation. These children are potential candidate for ventilation and it would make things easier for the anaesthetist to plan ahead.

Critical masses of nursing staff need to be trained in the use of CPAP. This should be supplemented by regular ongoing training. This may involve regular short term placement of staff in the neonatal unit.

All the resuscitation trolleys (in A&E and ward) should contain age appropriate intraosseous (IO) needles. IO with mechanical device (EZ- IO) to be considered for its ease of use.

The information gathered in this investigation to be shared with CATS so that learning points are shared and outcome of sick children can be improved

The information gathered in this investigation to be shared with the clinical team involved in this case so that learning points are shared and outcomes for sick children can be improved

UN Mum required early and timely intervention to support her parental needs

Reducing the time between the assessment and strategy meeting might have brought a different outcome.

This family required multi agency input, but there was no health care plan

There was a period when child was non-compliant on medication

Family support had been implemented but the Panel felt that management and escalation of the case might have improved outcomes.

There seemed to be a communication breakdown between professionals.

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Un/expectedClassification

Modifiable Factors / Recommendations

UN Recommendation from internal investigationBHRUT to have a medical discharge summary Standardised Electronic Neonatal Database (SEND) summary in place

Discharge summary to identify newborns with acute and on-going medical concerns, and give the care plan for primary care and hospital outpatient if appropriate.

Clinical outcomes for babies to be included in mothers postnatal notes for the attention of the community midwifeAwareness workshops for practitioners working with newborn babies

UN Issues identified areco-sleepingpoor parentingDomestic ViolenceSmoking Late antenatal booking.

UN Issues identified

The GP had not been aware of the private fostering arrangement

Health Visitor had not been aware of this child and therefore no visits were made to this child

Clubbing (a deformity of the fingers and fingernails) was not recorded in the GP notes. The Named GP, did say that unless the clubbing was brought to the attention of any GP, this would not be identified by the GP. Clubbing is a sign of respiratory problems, however it is only looked for in adults.

The Practice Nurse was concerned that child had attended the GP surgery without mother. This concern does not seem to have been taken forward by the Practice Nurse. A new policy has been created within the GP surgery where GPs are asked to record the name of the person attending with the child.

The New Patient registration was not carried out in full. There is a new registration policy being developed.

A Serious Investigation was not initiated until 54 days after the death. SIs are now considered earlier, at rapid response stage, within the CDOP process

Recommendations from BHRUT SITo ensure that there is an anaesthetist with experience of paediatrics who is comfortable looking after a critically ill child at all times

To ensure that the dedicated area for critically ill children is equipped at all times

To ensure that the Lead Consultant for Clinical Governance in both Paediatrics and Neonates to be involved in SIs with the

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Un/expectedClassification

Modifiable Factors / Recommendations

support of the General Manager

The post mortem reports to be sent to cliniciansTo identify the primary care team for every child that comes to A&E

To review the pathway for the care and management of critically ill children

To ensure that clinical staff have the appropriate training to manage a critically ill child

To provide training for clinical and administrative staff about the SI process

UN Issues identifiedPoor parentingPoor schooling attendancePoor condition of house – very neglectful conditions that resulted in a referral to children’s social care

UN There was no fire guard present in the home

There should have been greater and ongoing involvement of children’s social care by the preceding borough

Chair to present the case to preceding borough to determine why an internal investigation was not carried out.

UN Inappropriate feeding in a car seat

Should mum become pregnant again, mum should be booked as high risk

Women with history of mental health should be referred to perinatal mental health service

If mum becomes pregnant again, additional health visitor support with parenting and feeding practices should be provided. And, formally documented

UN Issue identifiedMum should have received more support around her communication abilities

EX Histology showed mum was the carrier of herpes simplex.CDOP agreed that BHRUT should have erred on the side of safety by starting treatment with anti-virals earlier.

EX Recommendations from BHRUT SIAll clinicians to be made aware of the importance of full documentation in the antenatal period as decision made may

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Un/expectedClassification

Modifiable Factors / Recommendations

impact on plans of care later in the pregnancy / labour.Audit of compliance against documentation standards for vaginal birth after caesarean (VBAC)Audit of standards of documentation carried out by supervisors of midwives.

Action plan in place to address any shortfall or areas of concerns.

All midwives to undergo review of their documentation and understanding of the requirements for documentation as part of the supervisory review with their own supervisor

Documentation and record keeping to be part of the new mandatory programme of training for the multi-disciplinary team and also a major component of the induction programme for midwives, nurses and doctors,

Review of current compliance with escalation policy to ensure escalation is not just based on bed capacity but is also related to workload and complexity and number of ‘high risk; cases.

Template to be designed to demonstrate hourly review of capacity / workload and ability of labour ward to manage.

National Patient Safety Agency (NPSA) score card to be used to keep record of 4 hourly capacity.

Matron for labour ward and lead obstetrician for labour ward to review pathways of care for the use of the four bedded area on the labour ward to include admission criteria and procedures for ensuring there is regular and timely review from the obstetric team and the Consultant ward round

The objectives should include interpretation of cardiotocography (CTGs), documentation of assessment and plans of care and documentation of communication with the client.

Feedback to midwife from her supervisor of midwives to include a review of notes and assessment of learning from the case

Audit of CTGs to be implemented with feedback to the education team for inclusion in CTG training.

Audit and findings to be shared with Labour ward matron to action with staff.

Report to be shared and discussion of findings at Serious Incident Group meeting, ward based meetings, risk newsletter, perinatal meetings, labour ward forum and doctors and midwife training sessions.

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Un/expectedClassification

Modifiable Factors / Recommendations

Action plan to be monitored through the Maternity Quality and Safety Committee.

Meeting to be arranged with relevant senior staff in maternity EX Issues identified

Mum was a high risk pregnancy and presented to triage and went home before being seen. There should have been a follow up call from the midwife. Nothing was recorded in the medical records to show that mum was advised not to leave etc.

EX Issues identifiedAn earlier emergency call / presentation to hospital might have prevented the onset of this labour.

Mum required an interpreter which might have also been a contributory factor

EX Recommendations from Serious Incident – BHRUTPolicy and Community guideline should be updated to reflect national guidelines.

A&E, Maternity and Neonatology should coalesce as a working group to provide a complete perinatal service for pregnant women and their babies.

A&E, Maternity and Neonatology medical/nursing/midwifery staff should receive designated training in-line with NICE guidance to manage neonatal jaundice process.

Active Trust-wide promotion and dissemination of the referral process for all midwives to the duty neonatal registrar/the duty paediatric registrar.

EX Recommendations from Serious Incident - BHRUT

The Triage and Transition pathway at the time of the incident failed to provide a safe and timely service. There are education and training issues in relation to CTG interpretation and expected actions, and in particular for sinusoidal traces.

The need for good quality documentation should be reinforced; staff falling below the required standards should undergo additional training and should have audits of their documentation undertaken to ensure improvement in standards.

The Labour Ward Coordinator should be clear about her sphere of responsibility and accountability. Communication would be better served by use of a tool to guide effective transfer of information.

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Un/expectedClassification

Modifiable Factors / Recommendations

The maternity service should work more closely with the transfusion service to ensure that women receive appropriate doses of anti-D immunoglobulin in an optimal timeframe.

The process of escalation should be reviewed for when care or service delivery is being impacted by acuity or staffing.

The neonatal service would benefit from a more contemporaneous method of capturing events / interventions during neonatal resuscitation.

The use of a scribe for emergencies (obstetric and emergency) would improve information capture and documentationSupervisor of Midwives review

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