Jackson Chadd

Frimley Park Hospital NHS}

NHS Foundation Trust

Frimley Park Hospital NHS Foundation Trust
Response to Regulation 28 Report for HM Coroner for Surrey
Re: Jackson CHADD

Background

The Trust received a Regulation 28 Report, Action to Prevent Future Deaths, from HM Coroner for
Surrey, dated 26 March 2014.

The Coroner had found the cause of death to be:
1a) Septic shock due to fulminant meningococcal infection

The Inquest concluded that the deceased died from fulminant meningococcal septicaemia where the
evolving nature of his illness was not recognised or treated.

The Coroner was advised that Jackson was a fit and healthy baby until he became unwell at home on
6 August 2012. He was irritable, not feeding well, crying with a temperature, tachycardia (160 bpm)
and a raised respiratory rate (>60). [MJ took the advice of her GP to go to A&E with a
possible diagnosis of her son having sepsis. Jackson was triaged in A&E at 5 p.m., found to have a
high temperature and a raised heart rate and respiratory rate. He was given paracetamol for his
temperature. He was reviewed by the A&E team who referred him to the Paediatricians with a
possible diagnosis of sepsis. He was then seen at approximately 7 p.m. by a non-career ST2 (GP
trainee) paediatrician who had been in post for one week with no previous paediatric experience.
Some tests were initiated for sepsis. A discussion was had between the ST2 and the Paediatric SpR
who, for unknown reasons, did not review Jackson.

Throughout this time in A&E, Jackson continued to have a high temperature (>38.5) that did not
settle with paracetamol or ibuprofen. His other observations were variable but remained abnormal
or at the upper limits of normal. No blood pressures were carried out after an attempt at triage
failed. During his time in A&E, Jackson had a number of bouts of severe, foul smelling diarrhoea and
developed a generalised maculo-papular rash with at least 2-3 noticeable non-blanching spots. He
was seen by the on-call SpR for the first and only time at 23.30, 7 hours after arriving in A&E.

Jackson was discharged with a diagnosis of gastroenteritis. No significance was placed on the rash or
the non-blanching spots. There is a conflict between his mother’s belief of how unwell her son was
(floppy, pale and lethargic with no obvious signs of improvement) and that of the SpR (smiling, not
floppy etc) and she was unhappy that Jackson was not admitted. Jackson was taken home but his
condition deteriorated and his parents brought him back at or around 0200 where he was found to
be in septic shock. Despite aggressive resuscitation, Jackson was certified dead at 06.05 on 7 August
2012.

Coroner’s Concerns
1. Lack of effective supervision of a non-career grade paediatrician with no previous experience

In Place at Time of Incident

e During working hours there are a minimum of 2 Consultant Paediatricians available within
the Trust, 1 dedicated to Neonates and the other to Paediatrics and acute admissions with
one consultant on-call and resident until 9 p.m.

e All junior doctors, including SHO level have a Consultant Clinical Supervisor and an
Educational Supervisor and are required to maintain portfolios of their development.

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Committed To Excellence Working Together Facing The Future

Military trainees have a Trust appointed Consultant Clinical Supervisor and a military
appointed Educational Supervisor. They have regular formal appraisals with their supervisor
and there is on-going shop-floor appraisal. This is in line with the requirements of both the
HEKSS & Military Deaneries and at the last review of the Paediatric service in November
2010 was noted to meet their standards.

e There is an identified College Tutor lead within the Paediatric Department. All new SHOs to
the Paediatric team will undergo a 3-day induction programme, 1 day Corporate Induction
plus 2 days local Paediatric Induction. A copy of the Paediatric Induction programme for
August 2014 is attached. In addition to this, there is a programme of Paediatric SHO
Teaching which covers a variety of subjects including ‘Recognition & Management of the Sick
Child’ and ‘NICE — an approach to fever in children’ (copies of the programme attached).

e There is no annual leave for Middle Grade doctors over the induction period for SHOs

e Middle Grade doctors do not attend Paediatric Out Patient Clinics during the induction
period for SHOs to ensure they are available to support the junior doctors during this period

e Paediatric handover takes place 3 times a day at shift changes and are expected to be
supervised by a Consultant during the week and one consultant supervised handover at the
weekend at 9.00 a.m., in line with Facing for the Future.

Actions Taken Post Incident Review

e Since the death of Jackson, there are always 2 Middle Grade doctors on duty 24/7 with a
Paediatric Registrar available in the Emergency Department 9 a.m. to 5 p.m. Monday to
Friday

Further Action Taken Post Coroners’ Inquest

e In place at the time of Jackson’s death there was an Escalation Policy whereby if a child was
in the A&E Department for more than 3 hours waiting for Paediatric opinion, the Consultant
should be informed. The SHO should now notify the Consultant if there is more than an
hour delay in senior review of a child.

2. Lack of consultant supervision of ‘out-of-hours’ on-call paediatric trainees

In Place at Time of Incident

e There is consultant presence in the Trust until 9 p.m. on weekdays, on-call after 9 p.m. with
a consultant available from 8.30 a.m. to 1 p.m. at weekends. Outside of these hours a
Consultant Paediatrician is on-call and expected to be able to return immediately if required.
This is standard practice in a District General Hospital.

e There is a clear expectation of the junior doctors that patients are discussed with
consultants with a low threshold of concern.

e Since the death of Jackson, a new Emergency Department Paediatric Consultant has been
appointed

Actions Taken Post Incident Review
e There is a Consultant responsible for Paediatric A&E working alongside an A&E consultant
with a Paediatric interest to supervise junior medical staff

Further Action Taken Post Coroners’ Inquest

e Further work is being considered by the Trust to strengthen a Paediatric Consultant
delivered service in moving towards 24/7 cover in line with the Keogh Standards.

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Committed To Excellence Working Together Facing The Future

3. Lack of independent consultant assessment of paediatric admissions in Frimley Park Hospital
outside normal working hours

In Place at Time of Incident

e In April 2011, the RCPCH published ‘Facing the Future: Standards for Paediatric Services’
which outlined Together for Child Health’ which includes the following criteria for review by
a consultant:

> Every child or young person who is admitted to a paediatric department with an acute
medical problem is seen by a consultant paediatrician within the first 24 hours. At the
last national audit of compliance with this criteria, the Trust scored 100%.

> At least one medical handover in every 24 hours is led by a paediatric consultant (or
equivalent). At the last national audit of compliance with this criteria, the Trust was
deemed to be compliant with this standard with 3 handovers on weekdays and one
handover at weekends

Actions Taken Post Incident Review

e The Trust is currently working to 14 hours for a consultant paediatrician review for every
child or young person who is admitted to a Paediatric department with an acute medical
problem

4. Lack of effective application of national guidelines for assessment and investigation of fever in
children less than one year of age

In Place at Time of Incident

e At the time of the incident, the Trust followed the NICE Clinical Guideline 160 on Feverish
Illness in Children which are available on the Paediatric section of the Trust intranet. As part
of the Induction process in Paediatrics, new medical staff are advised on where these can be
accessed. Sepsis is part of the induction programme in the first month of starting within
Paediatrics

e Asnoted under section 1, there is a programme of Paediatric SHO Teaching which includes a
specific session on the application of the fever guidelines

e  |f Jackson had been recognised as a seriously sick child, this would have been escalated to a
consultant immediately

Actions Taken Post Incident Review

e All children under the age of 1 with a PEWS score of less than 4 are now fast tracked to the
Paediatric Assessment Unit based on the Paediatric Ward for review

e Sepsis Guidelines have been updated to include tachycardia as per 2013 NICE

Further Action Taken Post Coroners’ Inquest

e The Paediatric SHO is to notify the consultant if there is more than an hour before senior
review of a child

e The Emergency Department uses a Paediatric Early Warning Score (PEWS) which must now
include a blood pressure reading when scoring every child

e Blood gases are to be done on all children presenting with a fever or non-blanching rash

e All children presenting with a non-blanching rash are to be admitted and treatment
considered

e The implementation of the Fever Guidelines is to be audited

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Committed To Excellence | Working Together Facing The Future

5. Failure to acknowledge or act on the concerns of a parent

e The Paediatric philosophy of ‘patient not happy to go home’ has a low threshold at FPH and
has been reiterated to all the junior doctors. The SpRs receive ‘Parental Concern’ as part of
their training

Conclusion

At the time of Jackson’s death, there was a clear framework in place for the induction and
supervision of junior doctors in training, arrangements for consultant assessment of paediatric
admissions as well as implemented guidelines for the assessment and investigation of children with
a fever.

However, it is recognised that on this occasion the processes in place were not followed and we
failed to recognise how seriously ill Jackson was. To strengthen the Paediatric service, changes in
practice were made both at the time of the incident review and since the Coroner’s Inquest into
Jackson’s death. Further work is being considered by the Trust to strengthen a Paediatric Consultant
delivered service in moving towards 24/7 cover in line with the Keogh Standards and with the aim of
prompt intervention and treatment of the acutely ill child.

=— ™

Clinical Director Paediatrics

Governance Manager

May 2014

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RCPCH
% 5-11 Theobalds Road
<et London WC1X 1SH
Royal College of
Paediatrics and Child Health

From_the President:

Dr Karen Henderson

HM Coroner’s Court

Station Approach

Woking, Surrey GU22 7AP 20" May 2014

Dear Dr Henderson

Jackson CHADD (deceased)
Regulation 28 — Action to Prevent Future Deaths

| have read carefully your notification above, and discussed this with senior colleagues within the
RCPCH in order to respond to your request for details and timescale for action to be taken.

The matters of concern listed are as follows:

1. Lack of effective supervision of a NCG Paediatrician

2. Lack of consultant supervision of out of hours on-call paediatric trainees

3. Lack of independent consultant assessment of paediatrics admissions into FPH outside
normal working hours

4. Lack of effective application of national guidelines for assessment and investigation of fever
in children less than 1

5. Failure to acknowledge or act on the concerns of a parent

Given that we do not have all the details of the case presented the RCPCH is unable to comment
on the specifics of the case. We have presumed that the hospital Trust will be responding on
local policies and procedures and their implementation relating to the above, and will be reviewing
and addressing any issues pertaining to the personal practice and competence of the staff
involved.

| am pleased to set out below the standards of care that we would expect and the work that is in
progress to develop further guidance in the areas where RCPCH can make a difference.

Medical Royal Colleges — background

Medical Royal College are membership-based professional bodies which set the standards for
training of specialist doctors in some or all parts of the UK and also contribute to development of
professional practice and service standards. All medical consultants in the UK are required to
pass professional examinations in their chosen specialty to maintain competence on a specialist
register including revalidation and continuous professional development, subject to approval by the
General Medical Council (GMC) which regulates the professions.

Alongside setting standards for doctors, Medical Royal Colleges, and their affiliated specialty
groups, provide expert clinical input to development of service and clinical standards. In England

the most widely recognised guidelines and standards are developed by the National Institute for
Health and Care Excellence (NICE) which has a rigorous and systematic process for topic
selection, identifying evidence, evidence synthesis, development, consultation, and final
production. Standards are developed in collaboration with expert clinical groups and stakeholders
such as medical Royal Colleges and, as could be expected, demand for new guidelines greatly
exceeds the capacity of NICE to develop them.

NHS bodies and individual clinical departments are expected to ensure that their operational
activities comply with NICE guidelines alongside service standards developed by professional
bodies such as RCPCH. There should be in place in all NHS organisations clear systems and
processes for clinical governance which monitor and audit practice and outcomes and design
programmes of on-going clinical training for staff. These arrangements should ensure that
clinicians remain familiar with the guidance relevant to the cases with which they are presented.

Paediatric service and supervision standards.

This case is one of four recent coroners’ cases which have come to my attention, three of which
have been referred to me under Regulation 28, and two of which have been referred also to the
Secretary of State. Whilst there were different factors relevant to each of the cases, there are also
common themes, and | believe it is important to consider the cross cutting issues in order to
respond to best effect.

The points which, to a greater or lesser degree, cross all cases are as follows:

e Adequate training of all healthcare professionals dealing with children
e Appropriate clinical decision support for healthcare professionals dealing with children
e Adequate consultant supervision of junior doctors dealing with children.

In this tragic case, we have linked your matters of concern to relevant standards and guidance in
order to set out our action.

e Items 1-3 relate to clinical supervision and availability of senior advice, for which the
‘Facing the Future’ standards (RCPCH 2011) apply as well as the
‘Standards for CYP in Emergency Care Settings (RCPCH Intercollegiate 2012).
° Item 4 relates to the NICE ‘Fever guidance’, CG160 which replaced CG47 in May 2013.
e Item 5is, in our opinion, a local matter for response by the Trust.

Facing the Future and emergency care standards (Items 1-3)

This document sets out ten standards for paediatric services, mostly based around acute settings.
It can be found on www.rcpch.ac.uk/facingthefuture and a summary of the standards is attached
below. The pertinent standards for Jackson's case would be

Standard 1 — children admitted are seen by a middle grade or above within 4 hours.
Standard 2 — children admitted are seen by a consultant or equivalent within 24 hours
Standard 3 - children referred are seen by a consultant, middle grade or suitably experienced
nurse.

In Jackson's case it appeared to take seven hours for him to be seen by a middle grade doctor
from arrival at the emergency department, but since Jackson was discharged and not admitted
standard 2 did not come into play.

Standard 8 on page 19 of the Emergency Care standards states that ‘systems are in place to
ensure safe discharge of children or young people including advice to families on when and where

to access further care if necessary’. The definition of ‘safe discharge is not provided but many
units have local policies in place that require consultant-led discharge of babies under 12 months
of age.

The ‘Facing the Future’ standards were audited in 2012 by RCPCH for compliance by units across
the UK. We found standard 1 was met by 77.4% of units and standard 2 by 87.7%. 99.2% met
standard 3. Although this case may have been compliant with our existing standards, our audit
report indicated that we were proposing to reconsider standard 2 amongst others with a view to
increasing the frequency of consultant review to twice rather than once in 24 hours. This review
has now commenced and will take around three months during which we will be collating any
evidence available to support the recommendations made. In parallel | have discussed this matter
with Professor Reid at Health Education England, and as a result our workforce team is working
with HEE to model the implications for medical staffing across the country were we to recommend
twice daily consultant review. Although it is clear that some children would still slip through the net,
even with twice daily consultant review, some parts of the country and some other specialties have
already set this as an expected standard of care. In the current environment where there is an
increasing emphasis on consultant-delivered care, | believe we have to say first and foremost what
we consider to be safest practice, albeit recognising that implementation may require considerable
changes to staffing and / or models of care.

NICE fever guidance

At the time of Jackson's death, the NICE fever guidelines were in place as CG47, but have since
been updated to CG160 to provide greater clarity on warning signs and actions required to identify
serious illness in children. NICE has produced a number of implementation tools and trusts are
encouraged to ensure that these guidelines are followed and adherence audited through clinical
governance processes. It s not clear from your summary the extent to which this was done by the
Trust in Jackson's case.

Why Children Die
Earlier this month RCPCH and NCB launched a joint report ‘Why children die’

http:// .tcpch.ac.uk/index.php?q=child-health/standards-care/health-policy/child-mortality/child-
mortali

This examines some of the possible reasons for the relatively high number of avoidable baby and
child deaths in the UK and provides in Part B a policy response of recommendations for remedial
action which include the following.

Better training for healthcare staff

e All frontline health professionals involved in the acute assessment of children and young
people should utilise resources such as the ‘Spotting the sick child’ web resource and
complete relevant professional development so they are confident and competent to recognise
a sick child

e Clinical teams looking after children and young people with known medical conditions make
maximum use of tools to support improved communication and clarity around on-going
management, for example: introduction of epilepsy passports or asthma management plans
where appropriate; cooperating with schools to meet their duty to support pupils with medical
conditions.

Whilst recognising that some children will still fall through the net, we are of the view that a higher
level of consultant supervision should be encouraged and are reviewing our standards accordingly.

This is also in line with the various 7-day consultant working documents’ and our own report on
consultant-delivered care’.

RCPCH has a policy priority to focus on reducing child death and we will continue to work with
NCB and other partners to press for continued action in this important area.

| trust this provides you with the reassurance that RCPCH is working hard to minimise the
likelihood of recurrence of what Jackson's family has faced; thank you for raising this important
case and reminding us of the importance of this work.

Yours sincerely

President

* http://www.england.nhs.uk/tag/seven-day-services/
? ttp://www.rcpch.ac.uk/what-we-do/workforce-planning/consultant-delivered-care/consultant-delivered-care