Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0356, written 6 Dec 2013. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Dec 2013 |
|---|---|
| Reference | 2013-0356 |
| Deceased | Millie Elizabeth Thompson |
| Coroner | John Pollard |
| Coroner area | Manchester South |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
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ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. fo REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. The Secretary of State for Education 2. The Secretary of State for Health 3. The Chief Executive of North West Ambulance Service Trust CORONER | am John Pollard, senior coroner, for the coroner area of Manchester South CORONER’S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. INVESTIGATION and INQUEST On the 26" October 2012 | commenced an investigation into the death of Millie Elizabeth Josephine Thompson. The investigation concluded at the end of the inquest on 5"" December 2013. The conclusion of the inquest was that Millie died from 1a Choking and a conclusion of Misadventure was recorded by the jury.. _| CIRCUMSTANCES OF THE DEATH On the morning of the 23 October 2012 Millie, then aged 9 months, was taken to Ramillies Nursery in Cheadle Hulme, Stockport, Greater-Manchester. This establishment which is registered with OFSTED caters for children from age 6months to 16 years. Whilst she was being fed Shepherd's Pie for lunch that day, she started to choke, she inhaled some of the food which eventually lodged in her left main bronchus, this led to her sustaining a tension pneumothorax leading to the cardiac arrest which was the underlying cause of death. When the call was made to the Ambulance service, the call taker wrongly assessed and allocated it thus meaning that a Rapid Response vehicle was not despatched. The crew of the first ambulance found that the oxygen mask that they had on their vehicle did not properly fit a very young child and they had to call for the assistance of a second crew. CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. — During the course of the evidence it became apparent that there were only a few members of staff at the Nursery who had undergone Paediatric First Aid training, and that there is a need for specialist training when confronted with certain medical conditions affecting very young children. Other members of staff had general First Aid training but this appears to have been less useful in the circumstances. It also transpired that the First Aid certification of some of the staff had lapsed by the passage of time, so that although they had undergone the training it now needed updating. The EMD (call-taker) for the Ambulance Trust is a non-medically trained person who simply takes the details and reads from the appropriate “card” as to what questions should be asked and what advice should be given as well as determining how the case is to be triaged and allocated. It appears that because of a misinterpretation by that person as to the question of “ineffective/effective breathing”, the case was wrongly allocated. | took the view that ALL nursery staff should be subject to mandatory paediatric First Aid training; that there should be better selection and training of Call-Taking staff for the ambulance service; that ALL emergency ambulances (including rapid response vehicles) should be equipped with suitable paediatric life-saving kit. 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you, jointly and/or severally, have the power to take such action. 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 3% February 2014. |, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 | COPIES and PUBLICATION | have sent a copy of my report to the Chi he following Interested Persons, on iii. of Millie), Ramillies Hall School, ChiePExecutive of Stoc port NHS Foundation trust and to the LOCAL SAFEGUARDING BOARD. | am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. ohn S. Pollard 9 | 6™ December 2013 H.M. Senior Coroner REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (2)
3 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
ae Department of Health POC1_ 829927 Mr John Pollard From the Rt Hon Jeremy Hunt MP Secretary of State for Health Richmond House 79 Whitehall London SWIA 2NS Tel: 020 7210 3000 Mb-sofs@dh.gsi.gov.uk Senior Coroner Coroner’s Court Mount Tabor Mottram Street “APG 9046 Stockport SKI 3PA De bef. Med, Thank you for your letter following the inquest into the death of Millie Thompson. In your report you state that Millie died from choking. Millie was being fed Shepherds Pie for lunch at the Ramillies nursery and started to choke. She inhaled some of the food which eventually lodged in her left main bronchus. This led to a tension pneumothorax leading to cardiac arrest which was the underlying cause of her death. When the call was made to the ambulance service it was wrongly assessed by the call taker meaning that a rapid response vehicle was not despatched. The call taker for the ambulance trust misinterpreted the information relating to effective/ineffective breathing and the case was wrongly allocated. When the ambulance arrived, the oxygen mask that was carried on the vehicle did not properly fit a very young child and so a second ambulance crew had to be called. You raise the following matters of concern and ask that we consider: e Only a few of the nursery staff had undergone Paediatric first aid training, You feel it should be mandatory for all nursery staff to take paediatric first aid training; ¢ There should be better selection and training of call taking staff at the ambulance trust; e All emergency ambulances should be equipped with suitable paediatric life- saving kit. I note that you have sent a copy of this Regulation 28 report to the Department for Education (Df) and the North West Ambulance Service Trust (NWAS).The training of nursery staff is the responsibility of DfE whilst the selection and training of call taking staff at the NWAS is a matter for the NWAS Trust. I believe that these two issues should properly be addressed by the DfE and the NWAS. With regard to equipping emergency ambulances with suitable paediatric life- saving kit, this is the responsibility of the individual Ambulance Trust. Officials have however, discussed this issue with colleagues at NWAS and can report that locally, all their emergency response vehicles, both ambulances and rapid response vehicles, are equipped with a range of paediatric emergency equipment as follows: Paediatric oropharyngeal airways Paediatirc Nasopharyngeal airways Layngeal masks Paediatric sized oxygen delivery masks Neonatal and paediatric bag-valve-mask devices for artificial ventilation Paediatric defibrillation pads Paediatric sized endotracheal tubes Paediatric laryngoscopes Cook IO needles — for intra-osseous access (drug/fluid administration) eeeeeeeee All of the above equipment may be used in the resuscitation of paediatric patients. In addition, we will share this Regulation 28 report, our response and the NWAS response with the Association of Ambulance Chief Executives so they can consider whether any further action or guidance is needed with regard to the equipping of emergency vehicles nationally. I hope that this response is helpful and I am grateful to you for bringing the circumstances of Millie’s death to my attention. Me pray Yen nn JEREMY HUNT
2013/0080195ETPO Edward Timpson MP Parliamentary Under Secretary of State for Children and Families Sanctuary Buildings 20 Great Smith Street Westminster London SW1P 3BT tel: 0370 000 2288 www.education.gov.uk/help/contactus John S Pollard — Senior Coroner The Coroner’s Court Mount Tabor, Mottram Street Stockport SK1 3PA Your ref: JSP/KA/02333-2012 aes 1G January 2014 Jolu, Thank you for your letter of 11 December, addressed to the Secretary of State, enclosing a Regulation 28 Report to Prevent Future Deaths, in relation to the inquest examining the death of Millie Thompson. | am replying as the minister responsible for this policy area. Millie Thompson’s death, while in the care of Ramillies Nursery in Cheadle Hulme, was a tragedy. | note that amongst your concerns about this case that you take the view that all staff working in nurseries should be subject to mandatory paediatric first aid training. The safety of children whilst being cared for by others is of paramount importance and staff with paediatric first aid training should always be available. Paediatric first aid training is, and will remain, a statutory requirement for all early years providers regulated under the Childcare Act 2006. The requirements for early years providers, including nurseries, are set out in the Statutory Framework for the Early Years Foundation Stage (EYFS). At least one person who has a current paediatric first aid certificate must be on the premises at all times when children are present, and must accompany children on outings. In July 2013 we published plans to further improve the quality and availability of childcare. In tandem with this publication, the Government launched a public consultation, “The Regulation of Childcare”, which ran from 16 July to 30 September 2013. The consultation sought views on proposals to amend the current childcare regulatory system and set out the measures needed to ensure children’s safety. As part of that, we proposed to reinforce the need that a first-aid trained member of staff must be available at all times. We also proposed to say more in the EYFS about the specific content of suitable courses. We expect to be able to publish the results of the consultation shortly during February 2014 and make any changes needed later this year. SA tery Edward Timpson MP Parliamentary Under Secretary of State for Children and Families
North West Ambulance Service NHS NHS Trust OUR REF: INQ/C/GM/12/187 Headquarters YOUR REF: CISP/KA/023333-2012 Ladybridge Hall DIRECTTEL: 01204 498 444 399 Chorley New Road Heaton, Bolton BL1 5DD Mr John S Pollard Tel: 01204 498400 ‘ Fax: 01204 498423 Senior Coroner www.nwas.nhs.uk The Coroner’s Court Mount Tarbor Mottram Street Stockport SK1 3PA RECEIVED 22 January 2014 31 JAN 2014 Dear Mr Pollard MILLIE THOMPSON (DECEASED) We write further to your letter of 11 December 2013, enclosing a Regulation 28 Report to Prevent Future Deaths in relation to the inquest examining the death of Millie Thompson. Please accept this as our response in accordance with Regulation 29(4). We note that you raise concerns regarding the: e selection and training of Emergency Medical Dispatchers (EMDs); and e paediatric life saving equipment carried by emergency ambulances. EMDs North West Ambulance Service (NWAS) is acutely aware of the importance of EMDs in relation to the care of patients. We have a robust, competitive recruitment process for EMDs, attracting approximately 300 applications for each vacant post. We continually review this recruitment and assessment process with the aim of ensuring only the most suitable and able candidates are appointed for this demanding and important role. All EMDs undergo a six week training course, covering policies and procedures, the call taking processes, first aid, including paediatric resuscitation, and use of the Advanced Medical Priority Dispatch System (AMPDS), which includes the ineffective breathing diagnostic tool. Successful completion of the course results in an internationally recognised qualification. In order to maintain their certification, EMDs must provide proof of continuing education and evidence of audit review, which provides a safeguard to ensuring their continuing competence in the role. They are also required to undergo CPR recertification every two years. radquarters: Ladybridge Hall, 399 Chorley New Road, Bolton. BL1 5DD , May, LON AINVESTORS fan ; SPN peopee | Chemmien We Delivering the right care, at the right time, in the right place ‘airman: Mrs M Whyham MBE ief Executive: Mr B Williams
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