Mikey Hornby

Bridgewater Community Healthcare INHS

NHS Foundation Trust

Chief Executive’s Office
Bevan House

17, Beecham Court
Smithy Brook Road
Wigan

WN3 6PR

Email:

Web: www. bridgewater.nhs.uk

23 January 2015

STRICTLY PRIVATE AND CONFIDENTIAL

Mr J Pollard

HM Senior Coroner
Coroner's Office

Town Hall

Stockport Borough Council
SK13XE

Dear Mr Pollard

Mikey James Hornby (Deceased)

Response to Regulation 28: Report to Prevent Future Deaths to Bridgewater Community
Healthcare NHS Foundation Trust

Please find below the response of Bridgewater Community Healthcare NHS Foundation Trust
following the inquest into the death of Mikey James Hornby and the Regulation 28 Report which

you issued on 15 December 2014.
Your concerns were set out in the Regulation 28 Report as follows:

“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:-
1. On the first attendance at the Out of Hours Service, the attending staff having seen the

infected umbilical cord, did not immediately send Mikey to the Hospital (as would have
been the correct procedure according to the Consultant Lead Paediatrician who gave

evidence to me).

Chief Executive: Dr Kate Fallon Chairman: Harry Holden

Headquarters: Bevan House, 17 Beecham Court, Smithy Brook Road, Wigan, WN3 6PR

2. On the second attendance the doctor failed to appreciate the seriousness of the situation
and at 10.45 at night sent the child home with a prescription for analgesia (which could not
be filled until the following day in any event). The Consultant Paediatrician gave evidence
to me “that there was a very high probability that he would have survived” had he been
sent to the hospital at this time as he could and would have been administered an intra-

venous anti-biotic.

3. If there is any realistic possibility of the condition being meningitis, the child should have
been immediately admitted to the hospital.

4. The GP covering the surgery that night indicated that they do not have the facility to take a
simple blood test. If this is the case, then they should utilise the adjacent facilities at the

Emergency Department of the hospital.”

You also indicated that in your opinion, “there is a very clear training need identified here, in
relation to the appreciation of this type of occurrence with very young children”.

Response of Bridgewater Community Healthcare NHS Foundation Trust
1. Procedures for referral from out of hours to Hospital

In 2013, the Trust implemented national NICE guidance dated May 2013 entitled “Feverish
illness in children: Assessment and initial management in children younger than 5 years” which is
based on validated algorithms. A copy of a link to the NICE guidance is enclosed, for your ease
of reference: http://www.nice.org.uk/guidance/cg160/chapter/recommendations.

The Trust is fully compliant with this guideline. The Trust uses the Paediatric Early Warning
Score (PEWS) system in the GP Out of Hours service as a way of ensuring that the steps
recommended in the NICE guidance,age considered (please see attachment one). Although the
score sheet was not available during I examination of Baby Mikey, running the score from
the clinical data of the consultation the score is 0-2 which did not indicate further action was

required.

If either EE or ME hac decided that further action was required, there is a well-defined
pathway for referral of patients to the Paediatricians at the hospital.

The Trust reviewed the care provided to baby Mikey through its Root Cause Analysis process,
which concluded in May 2014. This included review b' peers within the organisation. The root
cause analysis investigation concluded that — complied with NICE guidance in his
assessment of baby Mikey but that more attention could have been given to his feeding pattern
and the possibility of dehydration. Appropriate safety netting advice was also provided.

The Root Cause Analysis undertaken by the Trust did identify areas of learning, namely:

1. Ensuring a full history is taken from the parents when assessing babies, in particular in
relation feeding patterns.

2. Ensuring that documentation (the PEWS sheet) is available to practitioners on the
electronic system.

3. Ensuring that information can be shared between organisations easily and quickly.

2. Blood tests within the out of hours service

In common with any GP practice, the GP Out of Hours service does not routinely take blood from
children, including urgent circumstances, as we would not receive a report back in a timely
enough manner to influence our decision making. If a practitioner felt that a blood test was likely
to be important to the clinical decision making process, there is a clear referral protocol to the
Paediatric department. A&E is not a referral route that we would use as there are pathways for
an emergency referral to be made dir to the Paediatricians rather than patients waiting
unnecessarily in A&E. At the time saw the patient, a blood test was not deemed
necessary, as evidenced through the NICE guidelines but if it had have been, an emergency

referral to the Paediatricians would have been made.

Although it is unlikely to have affected the outcome in this tragic case, we have internally reflected
that the Out of Hours drug cupboard stock of paracetamol should have been used rather than
issuing a prescription at that time of night, particularly in the light of the age of the baby. This has
been communicated to practitioners within the service, and we are sorry that it did not occur in

this case.
3: Training

All new staff undertake both a corporate and a local induction to ensure they are aware of the
policies and procedures in place as they take up post. Any new or reviewed Policies, Procedures
and Guidelines are cascaded to clinical and medical staff with advice on the areas that need to
be supported in practice via a bulletin to staff (examples included — please see attachments two
and three). Significant guidance such as the new NICE advice on feverish illness in children is
implemented into practice with templates to support assessment and management of care.

Ongoing checks on the quality of the services we provide are made via quarterly clinical audit
reviews, where a sample of clinical and medical records from each Practitioner are reviewed by
the clinical director enabling best practice to be recognised and shared with colleagues. Where
best practice is not followed a period of supervision and formal Support with competency

improvement action plans is implemented.

Annual appraisals take place with all staff. Learning from incidents in service allows GPs to
review their training needs so that alongside maintaining their annual Mandatory and Statutory
Training, particular development needs can be met. For GPs in the Out of Hours Service, their
Bridgewater-specific training will often run alongsi le continuing professional development
they undertake as part of their practice. cs case, he has undertaken training on
management of the severely ill child to support his general practice role.

You may be aware that the Warrington Safeguarding Children Board is undertaking a local review
of the case and | will share a copy of your Regulation 28 report with the reviewers. If you would
wish to be kept informed of the outcome of the review, please do let me know.

| hope that this response provides assurance that the policies and Practices implemented by
Bridgewater Community Healthcare NHS Foundation Trust are in line with national guidelines
issued by NICE. The Trust reacted very swiftly to the extremely sad news of Mikey’s death. We
would like to extend our sincere condolences to his family and have met with them as part of the
Trust’s complaints process. We would of course be happy to meet again if the family would find

that helpful.

Please do not hesitate to contact me if you require any further information in relation to our
response.

Yours sincerely

r Kate Fallon
Chief Executive

Enc

BE consuttant Paediatrician)

Mr Nicholas Rheinberg (HM Senior Coroner for Cheshire)

— Inspector, Hospital Directorate
Care Quality Commission

>fyour community Bridgewater Community Healthcare NHS)
— NHS Trust
Warrington OOH/Urgent Care GP unit
Bulletin

August 2014

Hi all,
Hope you have enjoyed or are on a break.

Continued thank you for all the hard work that you put in to keeping the service
running.

1. Rotas:

Please can everybody check the rota for PCUCU and OOH when they
arrive, they normally come out 4 weeks before the start of the rota. There
are still occasions when people have been down for a shift incorrectly and
not realised thus effecting the service provision or have not turned up as

they did not know they were working.

Can | ask EVERYONE (even if you think you are not working) to
THOROUGHLY check the rotas and inform the office IMMEDIATELY of any
errors, this allows for correct staffing and cover to be arranged.

2. Car Parking:

Warrington hospital has changed the car parking system.
Further information will be forthcoming once the hospital works out what it is

doing!

3. | am pleased to report that we once again were 97% compliant in our
record keeping.

4. CQC: CQC will at some point be visiting and reviewing the OOH services
you should have all received an email from Sharon highlighting the key
areas that will be assessed. You should have seen that the majority of these

are already compliant.

5. Streaming: There have been occasions when a shift cannot be covered (see
point 1) or due to illness, this has meant that the services have had to
merge. AED have always been informed of this and that streaming will

continue as normal.
It is essential that we keep the service running smoothly as much as

possible.

6. An incident occurred back in April involving the OOH service and a young
child, the child was seen by OOH the night before he sadly passed away.
The records and the reports by those involved have demonstrated an
excellent level of care delivered by the OOH service; this has been possible
to review due to the high quality note keeping (as highlighted in point 3)

The case is now under the remit of the coroner’s court.
The post mortem showed an E.Coli infection via the umbilicus

A letter has been written by Paediatrics which | have been asked to
disseminate to you all:

IDENTIFICATION OF UMBILICAL INFECTION OMPHALITIS)
Insert Date: 10"” August 2014 ]
Alerts are circulated to raise awareness of risks that may lead to errors and reduce the risk to patients, staff, visitors and
contractors in the future. They are produced following a review of systems, procedures, incidents or following information
provided by staff within the Trust or by an External Agency.

Notification to all staff involved in care of children

Situation: The incidence rate for umbilical infection is between 2-7/1000 live births. In developing countries, the
incidence of omphalitis varies from 2 to 7%. Overall mortality rate is 7-15%. With complications, as meningitis,
necrotising fascitis and myonecrosis, the mortality rate is 38-87%. Risk factors for poor prognosis include male sex,
prematurity or being small for gestational age, and septic delivery (including unplanned home delivery).

Background: An 11 days old male infant who died suddenly and unexpectedly at home showed disseminated E Coli
infection with meningitis on autopsy The family has had visits from the community midwifery team during the first week
of his life and the infant was thought to be healthy. The infant was treated for umbilical infection with topical Fucidin on
day 6 of life. One day before his death, the infant was having fever and respiratory difficulty and prescribed paracetamol.
The infant was feeding poorly and had lost around 20% body weight (from birth weight).

Assessment and Risk:

In most healthy babies the umbilical stump drops off between 7-
after a few days, when the stump has dried and sealed. In some
the stump has fallen off. It's normal for the stump to look a bit mucky as it’s healing,
base. This doesn’t mean that it’s infected

The stump itself will then shrivel up, turn black, and drop off. There is a small wound that will heal and becomes the

belly button.

10 days after birth. The plastic clamp is taken off the tie
areas, the midwife will leave the tie or clamp on until
or to have some moisture at the

Omphalitis
Umbilical infection is caused by both gram positive, gram negative and sometimes by anaerobic bacteria. It is important
to ensure that health professionals identify infants with umbilical infection and regard it as a medical emergency for the

infant's hospital transfer and treatment with intravenous antibiotics.
Symptoms that may suggest presence of infection include poor feeding, vomiting, irritability, respiratory difficulties or
skin rash. Fever is present in less than 33% of neonates with sepsis and over 66% infants present with normal or low
core temperature.

Features of uncomplicated omphalitis include:

Purulent or malodorous discharge from the umbilical stump
Periumbilical erythema or oedema

Periumbilical tenderness
Presence of petechae, vesicular or pustular lesions

It is recognised that the initial neonatal examination is usually normal and the symptoms and the signs of umbilical
infection evolve following discharge from the hospital. All medical, nursing and community team should strongly consider
the possibility of Omphalitis in all infants presenting with local or systemic signs of sepsis.

Recommended Action: Would all GP’s, midwifery team, health visitors practice Managers and Heads of Children’s
Services in the hospital and the community kindly communicate to their staff as Part of any communication briefings.

For further information or other queries, please contact: Dr Nisar Mir, Consultant Paediatrician Warrington & Halton

Hospitals NHS Foundation Trust

7. An invite has been sent out regarding a Paediatric Symposium:

Dear Colleague

On behalf of the team, | am delighted to announce that the first Paediatric
Symposium will be held on the 20th of November 2014 at Statham Lodge
Hotel, Lymm from 9am to 13.00hours, followed by lunch.

All GPs, GP registrars, Nurse Practitioners and Practice nurses with an
interest in Paediatrics are invited to attend.

There will be four educational workshops run by eminent speakers lasting
about forty minutes each. All delegates can attend the four sessions.

Details of speakers, format and topics will be shared early September.
If you would like to attend, please email Jan Todd or myself:

Jan. Todd@warringtonccg.nhs.uk
ichatterjee@nhs.net

Regards

Ipsita

If there are any issues please email me neilfisher@nhs.net

Nell Fisher
Dr Neil Fisher

Clinical Director Urgent and Primary Care.

Bridgewater Community Healthcare NHS Trust.

bridgewater
dealthcare at the heart . .
=i Bridgewater Community Healthcare

NHS Trust

_——————

Warrington OOH/Urgent Care GP unit
Bulletin

June 2014

Hi all,

1. The weekend of 215/22" June was very busy across the unscheduled
system of primary and secondary care. The sister in charge of Paediatric
AED sent her thanks to the staff on in PCUCU and OOH for their assistance
in relieving the pressure that had developed in Paediatric AED.

2. No issues have arisen from the last staff meeting, this monthly meeting is
between reception staff and management, it has been requested for clinical
representation to be present and | attended on the 26" June, if any other
clinicians would like to attend then let me know.

3. NWAS: below is an email bulletin from our colleagues, please take time to
read this, it is for information purposes only. It especially applies to OOH ,
but may occur in PCUCU (although all attempts should be made to speak to

patient’s own surgery during open hours)

Thanks for taking the time to read this e-mail. | just wanted to mention an issue that occurred a few months ago,
and to ensure that you and your staff are aware of NWAS procedures surrounding patient refusal to attend
hospital. | appreciate that the incident is not a recent one, and that you may already have addressed it, however |
wanted to highlight this problem in order to ensure that you and your staff were fully conversant with the method

of triage and referral employed by our staff.

The incident involved one of your GPs. The issue arose as the NWAS ambulance crew were called to a patient
who, they felt needed to attend hospital. Despite the crew's attempt to persuade the patient to travel to hospital
with them, the patient refused. As the patient had full mental capacity, the ambulance crew were obliged to
accept this, and attempted to make a referral to your service, in order to ensure that some kind of safety net was
put in place for this patient. The Dr in OOH initially refused to accept this patient as they said that the referral
was inappropriate. In a later phone call they did subsequently change their mind regarding this and did agree to
accept the referral, although still saying that they thought it was inappropriate.

My concern regarding this incident is that they did not appear to understand the triage process undertaken by the
ambulance crew and that the crew had attempted to take the patient to hospital. As the patient had full mental
capacity and had refused hospital treatment, the patient fell into a category known colloquially as a “Red
Refusal.” This is a patient who has been assessed using our triage too! as high risk, but who has refused
hospital treatment. For this patient group, NWAS staff have no option other than to refer to the GP services My
purpose in contacting you is to ensure that you and all your staff are familiar with the NWAS assessment and
triage process. | am most happy to come and talk to your staff, in order to explain the NWAS assessment
process, our triage tool along with its strengths and its limitations, and to highlight areas where ambulance staff
may make referrals to your service that may, on the face of it, appear unsafe. Please do not hesitate to get in

touch if you feel that | can be of any help to you in this matter.
Regards,

Jane Clayton
Advanced Paramedic

Cheshire and Mersey East
North West Ambulance Service
Tel: 07812 305620

4. Complaints:

There have been a couple of incidents recently involving OOH that
demonstrate common themes. Listening to patients and Communication

Listening to patients:
Under GMC guidelines: Good Medical Practice:

Work in partnership with patients.

o Listen to, and respond to, their concerns and preferences.
o Give patients the information they want or need in a way they can

understand.
o Respect patients' right to reach decisions with you about their

treatment and care.
o Support patients in caring for themselves to improve and maintain

their health.
Communication:
The Health and Social Care Information Centre (HSCIC) report into
complaints 2012/13 showed:

In Hospital and Community settings:

46.2% of complaints were in respect of all clinical treatment
11.1% due to attitude of staff
10.5% due to communication
8% due to appointment delay

In Primary Care:
35.5% due to clinical issues
20.8% due to communication/attitude of staff

19.5% due to admin issues.

5. Note taking:

As | have stated in the last couple of weeks, it is the individual's
responsibility to record their consultations.

Good Medical Practice states:
Record your work clearly, accurately and legibly:

o 19. Documents you make (including clinical records) to formally record
your work must be clear, accurate and legible. You should make

records at the same time-as the events you are recording or as soon as
possible afterwards.

o 20. You must keep records that contain personal information about
patients, colleagues or others securely, and in line with any data
protection requirements.

o 21. Clinical records should include:
o a. relevant clinical findings
ob, the decisions made and actions agreed, and who is making
the decisions and agreeing the actions
c. the information given to patients
d. any drugs prescribed or other investigation or treatment
e. who is making the record and when.

°

ie}

fe}

6. Distance from service: an email was sent out on 23 June, in case you did
not receive it:

Dear all

Further to a management meeting today regarding OOHs.

For the service to meet its local and national quality standards the service needs to demonstrate its
ability to respond in an appropriate time.

This is especially important overnight:

If you are able to state that if called overnight you can be picked up and at the patient's house seeing
the patient within 1 hour (wherever in Warrington the patient is) then you are able to cover the
requirements, as set out in the OOHs quality standards.

If you cannot then do not request 1 -6 shifts, please.

Likewise it is your responsibility to write on TPP your consultation notes, this can either be real time
via the Toughbook, or back at the base after, or (as long as the times are correctly entered, and the
call handler has been informed) can be done first thing in the morning in your own surgery. It is not
acceptable practice to hand write, dictate or email for the call handler to input.

The monthly bulletin is in the process of being written, if anyone has anything they want adding for
general consensus or discussion then please let me know.

Thanks as always for the hard work.
7. Rotas:

Please can everybody check the rota for PCUCU and OOH when they
arrive, they normally come out 4 weeks before the start of the rota. There
have been a couple of occasions when people have been down for a shift
incorrectly and not realised thus effecting the service provision.

Can | ask EVERYONE (even if you think you are not working) to
THOROUGHLY check the rotas and inform the office IMMEDIATELY of any
errors, this allows for correct staffing and cover to be arranged.

8. Car Parking:

Warrington hospital is in the process of changing the car parking system,
please ensure all registration numbers are correct, they are the OOH folder
on the K drive. Further information will be forthcoming once the hospital

works out what it is doing.

9. TPP dispositions:
The office has asked me to pass on the following:
If it is a ‘speak to clinician’ DX11 — this needs a clinician call back or re prioritisation —
rather than being issued an appointment. The result has been an appointment offered has
breached 2-3 hours out of time. If the appointment is unable to be given within the time
then an exception should be recorded (usually by the receptionist) but may be the

clinician/doctor

If that makes no sense please speak to Dawn Richards (Operational
manager for OOH) in the office.

10. Attached to the email is the latest Bridgewater Staff Briefing.

Thanks for all the hard work you put into the services, if there are any

issues please email me neilfisher@nhs.net

Neil Fisher
Dr Neil Fisher

Clinical Director Urgent and Primary Care.

Bridgewater Community Healthcare NHS Trust.

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PEWS Escalation Aid

Situation: Remember: If you feel you need more help at any time,
! am (name), a nurse on ward (X) call for help — regardless of PEW Score

1am calling about (child X)

1am calling because | am concerned that... :
(e.g. BP is lowhigh, pulse is XXX 0) e Continue monitoring

temperature is XX, Early Warning Score is XX)

Background: @ Nurse in charge MUST review

Child (X) was admitted on (XX date) with
(e.g. respiratory infection)

They have had (X operation/procedure/investigation) 3 Nurse in Charge & Doctor
Child (X)’s condition has changed in the last (XX mins) MUST review

Their last set of obs were (XXX)

The child's normal condition is...
(e.g. alert/drowsy/confused, pain free)

Assessment:

| think the problem is (XXX)
and | have... ;
(e.g. given 02 /analgesia, stopped the infusion) 4 Nurse Us) Charge & Doctor MUST
on review & inform Consultant

! am not sure what the problem is but child (X)
is deteriorating

OR

! don’t know what's wrong but | am really worried |

Recommendation:
1 need you to...

Come to see the child in the next (XX mins) Nurse in Charge & Consultant
AND

Is there anything | need to do in the meantime?
(e.g. stop the fluid/repeat the obs)

Download SBAR prompt cards and pads at
www.institute.nhs.uk/SBAR

Print Name

Date Time

Taga ED consultant called Anaesthe: ee itn
09:00 ? review ) |Sister JACKS

01/01/12 |

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