Gianna Khan

INHS|

Luton
Clinical Commissioning Group

This is a response to the request from HM Coroner, Mr Tom Osborne, to provide information under
Paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the

Introduction

Background

Coroners (Investigations) Regulations 2013 Action to Prevent Future Deaths.

Evidence given at the inquest touching the death of Gianni KHAN revealed matters
giving rise to concern to HM Coroner with regards to the ‘streaming’ arrangements for
children with head injuries between the Luton and Dunstable University Hospital
Emergency Department and the Urgent General Practitioner Clinic. HM Coroner has
requested that |, as Chief Officer of Luton Clinical Commissioning Group, detail any
action that has been taken, or which | propose to take, in line with Regulations 28 and
29 of the Coroners (Investigations) Regulations 2013: Action to Prevent Future Deaths.

The Urgent GP Clinic was set up in December 2011 with the aim of providing a GP based
service on the Luton and Dunstable University Hospital (LDH) site, as an element of an
integrated approach to unscheduled care.

Whilst being co-located on the Luton and Dunstable University Hospital site it is
independently run by Local Healthcare Solutions (LHS) and commissioned by Luton
Clinical Commissioning Group (LCCG). It registered with the Care Quality Commission
(CQC) in April 2013.

The Clinic operates as a GP surgery between the hours of 08.00 and midnight, 7 days a
week, only accepting patients streamed by the hospital’s Emergency Department (ED)
using agreed protocols. These are patients with an urgent and unplanned healthcare
requirement that necessitates a timely and direct health intervention in a primary care
setting.

For this integrated service, streaming protocols were developed jointly with the Luton
and Dunstable University Hospitals Emergency Department Clinicians and the
Commissioner (Luton Clinical Commissioning Group). These are regularly reviewed at
the Joint Service Review Meeting.

Between January and December 2013 the number of people attending the Emergency
Department at the Luton and Dunstable University Hospital was 116,242 of which
37,564 were streamed to the Urgent GP Clinic.

The streaming is undertaken by a designated nurse who is a competent Emergency
Department nurse and qualified to perform this role. Luton Clinical Commissioning
Group fund a band 7 post, however the nurse is employed and managed by the Hospital.
At the time of the incident a band 5 nurse was undertaking the streaming role as the
designated nurse was taking a break.

On Saturday 21 December 2013 ten year old Gianni Khan attended the Luton and
Dunstable University Hospital with his mother as she was concerned for his well-being
after he had suffered an accidental blow to his head.

The streaming nurse, following the agreed protocol, made a judgement that no further

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Action Taken

intervention would be necessary and felt that the child’s condition could be managed
within a primary care setting. He was therefore ‘streamed’ to the Urgent GP Clinic
(UGPC).

It should be noted that streaming and triage are completely different processes,
although at HM Coroner’s inquest into Gianni’s death, it was evident that this difference
was not clearly understood.

Streaming is a system whereby patients are allocated to different pathways according to
their needs. All ambulatory (able to walk) patients attending the Emergency Department
are given an immediate visual assessment and ‘streamed’ by a competent Emergency
Department nurse to either remain in the Emergency Department or be directed to the
primary care setting of the Urgent GP Clinic.

For those patients who are considered to be appropriate for assessment and treatment
at the Urgent GP Clinic, the Emergency Department receptionist records key patient
demographic information and enters it onto SystmOne, the Clinical Registration System
for Primary Care. They are not entered onto the Luton and Dunstable University Hospital
Patient Information System.

Triage is an initial face to face, hands-on assessment by medical or nursing staff in the
Emergency Department which determines a patient's priority for treatment and informs
their urgency of need for further assessment or intervention.

The Luton and Dunstable University Hospital agreed to the ‘streaming’ of appropriate
patients to the Urgent GP Clinic on the understanding that if a patient subsequently
deteriorated they would be referred back to Emergency Department. Sadly, in this case,
Gianni was not referred back and HM Coroner and our Serious Incident Overview Report
concluded that this may have contributed to his death.

Following Gianni’s death and the subsequent investigations by all health organisations
involved, Luton Clinical Commissioning Group, carried out an assessment of the risk
relating to children being streamed into the Urgent GP Clinic with head injuries. This
was undertaken using the Clinical Commissioning Group’s risk matrix (provided for
reference in Appendix A). This established that the likelihood of harm occurring to
children being streamed to the Urgent GP Clinic was ‘unlikely’ (0.1-1%) however the
consequence/impact of that harm could be ‘catastrophic’ (incident leading to death),
which led to an assessed risk rating of ‘high’.

In order to mitigate the risk, following the inquest on 28 April 2014 and our Serious
Incident Overview Report, Luton Clinical Commissioning Group, the Luton and Dunstable
University Hospital and the Urgent GP Clinic agreed to exclude the following patient
groups from the streaming protocol with immediate effect:

1. Any child? with a Head Injury

2. Any child conveyed to Luton and Dunstable University Hospital by ambulance

3. Babies 6 months and under

Patients from within these groups are now all assessed and managed within the
Emergency Department.

* A child in emergency medicine is defined as a person up to their 16 birthday

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Further
Action
Required

Reassessment of the risk following implementation of the above actions has determined
that the likelihood of harm to children is ‘rare’ (<0.1%)} and the consequence/impact
‘negligible’. The risk rating has now been reduced to ‘low’.

Additionally, Luton Clinical Commissioning Group has enhanced its monitoring of the
Urgent GP Clinic by ensuring regular monthly performance (Joint Service Review)
meetings.

An extraordinary meeting, chaired by Luton Clinical Commissioning Group and attended
by representatives from the Luton and Dunstable University Hospital and the Urgent GP
Clinic, was held on 20th May 2014. The purpose of the meeting was to identify, analyse,
control and evaluate any further risks associated with the streaming protocol and agree
the management of those risks.

Luton Clinical Commissioning Group is absolutely committed to ensuring that the people
of Luton receive a high quality, safe service when attending for emergency or urgent
care and the following are further actions required to achieve this.

The Urgent Care Strategic Implementation Group will undertake a comprehensive
review of the streaming process for both adults and children.

The Luton and Dunstable University Hospital will provide information on the impact of
the changes to streaming on ED activity at 3 and 6 months to Luton Clinical
Commissioning Group in respect of the following:

¢ number of children presenting to the ED

© number of children with a head injury

¢ number of children presenting under 6 months

* number of children conveyed by ambulance

The Luton and Dunstable University Hospital will provide head injury data analysis as
requested by Luton System Resilience Group (previously Urgent Care Working Group),
including a review of those cases presenting with head injury that developed into a
serious/complex case. This will be analysed and acted on accordingly.

Our report on the investigations into this case identified inconsistencies in use of the
locally developed Clinical Assessment Tool for Head Injuries in Children. The tool was
developed by Luton Clinical Commissioning Groups Children’s Strategic Implementation
Group and forms one of seven Paediatric Urgent Care Pathways (head injury; fever;
bronchiolitis; gastroenteritis; asthma; seizures; abdominal pain). These Urgent Care
Pathways are based on NICE? guidance, are submitted to NICE’s shared learning
collection and previously have been positively quality assured and published on the NICE
website. They are scrutinised annually against any change in guidance and seek quality
assurance as needed from NICE.

The Clinical Assessment Tool for Head Injuries in Children is currently undergoing its
review in line with NICE CG176 published in January 2014. A further improvement will
see good version control identified on all pathways and procedural documents, to
ensure the most up to date information is available and utilised.

eee
* National Institute for Health and Care Excellence (NICE)

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Based on the findings in the Serious Incident Overview Report of the incident, Luton
Clinical Commissioning Group developed a list of recommendations, for both the
provider organisations and the Clinical Commissioning Group itself.

Luton Clinical Commissioning Group will:

¢ Undertake a comprehensive review of the streaming process for adults and
children and all streaming protocols currently in place, including exclusion
criteria.

¢ Ensure that the review encompasses consideration for triage before streaming,
streaming protocols and other national requirements for urgent and emergency
care.

* Share the Serious Incident Overview Report with the 3 healthcare providers
involved in the incident and ensure it is disseminated to all front line staff for
review and discussion at team meetings to inform learning.

* Continue to improve on processes to gain assurance that Local Healthcare
Solutions delivers their service against national risk management standards.

¢ Review and oversee clinical governance meetings between the Luton and
Dunstable university Hospital and the Urgent GP Clinic to ensure an integrated
approach and robust monitoring of service quality.

For the providers, Luton Clinical Commissioning Group recommends, will monitor and
ensure completion on the following:
* Review and implement NICE CG176 with assurance to Luton Clinical
Commissioning Group that this has been achieved.
¢ Assurance to Luton Clinical Commissioning Group on how policies and
procedures are shared throughout provider organisations. This must include the
process for updating changes within current procedural documents.
* Review of systems and organisational factors that may lead to gaps in
underpinning knowledge.
¢ The Serious Incident Overview Report to be disseminated to all front line staff
for review and discussion at team meetings to inform learning.

An action plan has been developed (appendix B) to facilitate robust monitoring of the
above actions, which will be monitored through existing provider quality governance
processes.

Additionally, through their own investigation of the incident, the Luton and Dunstable
University Hospital agreed to the following:
e Refresh training for all staff involved in the streaming of patients from the
Emergency Department to Urgent GP Clinic

Similarly, Local Healthcare Solutions have agreed and/or implemented the following:

¢ AHead Injury is now described as ‘any injury above the chin including a facial
injury’

¢ An information notice advising as to what services are provided in the Urgent
GP Clinic has been displayed in the Urgent GP Clinic by the reception desk

* Local Healthcare Solutions is in the process of carrying out an audit on all its
record keeping and will, when complete, share the findings with Luton Clinical
Commissioning Group

° Local Healthcare Solutions has accepted NICE Guidance CG176 Head Injury as
the only acceptable standard at the Urgent GP Clinic for managing patients

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presenting with Head Injuries

e Local Healthcare Solutions will co-operate fully with NHS England GP
Performance Team during any investigation into the performance of any
clinician involved in this case

¢ Local Healthcare Solutions is in the process of resubmitting its ‘Risk and Serious
Incident Framework’ for scrutiny and evaluation to Luton Clinical
Commissioning Group Quality Department

Whilst the East of England Ambulance Service has agreed actions in response to their
investigation findings these have not been included in this response as they do not
constitute part of the streaming process. They are covered in the overarching action
plan which will be monitored by Luton Clinical Commissioning Group.

There are also additional actions for Luton Clinical Commissioning group to improve
processes that were identified within the Serious Incident Overview Report but again do
not constitute part of the streaming process.

A key priority for Luton Clinical Commissioning Group will be a thorough review of
emergency and urgent care commissioning arrangements in line with the findings of this
investigation and Keogh? (2013) through a longer-term piece of work. This will be
reflected in commissioning arrangements for 2015/16.

Luton Clinical Commissioning group will work with the relevant provider organisations
to ensure all recommendations are risk assessed, actioned and implemented in line with
our quality governance processes and Regulations 28 and 29 of the Coroners
(Investigations) Regulations 2013: Action to Prevent Future Deaths.

5 Keogh B. (2013) Transforming urgent and emergency care services in England - Urgent and Emergency Care
Review - End of Phase 1 — Report; High quality care for all, now and for future generations.

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