Marc Poole

Doncaster and Bassetlaw Hospitals INHS|

NHS Foundation Trust

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Care r

Medical Director’s Office

Mr S Singh, Medical Director (3630)

Mr R J Cuschieri, Deputy Medical Director — Clinical Standards (642150)

Dr R Harris, Deputy Medical Director — Professional Standards (642124 or 75 2275)
Karen Humphries, Clinical & Professional Standards Co-ordinator (642149)
Jacqueline Ford, Executive PA to Medical Director (3183)

RC/js
23 March 2016

Ms N J Mundy

Senior Coroner

South Yorkshire (East District)
Coroner’s Court and Office
Crown Court

College Road

Doncaster

DN1 3HS

Dear Ms Mundy

RE: Marc Jason Stephen Poole (Deceased)
D.O.B: 29 September 2008
D.O.D: 18 May 2015

Thank you for your letter of 8 February 2016 addressed to Mr Mike Pinkerton, Chief
Executive, Doncaster & Bassetlaw NHS Foundation Trust.

With respect to the concluded inquest on Marc Jason Stephen Poole the Regulation 28
report dated 2 February 2016, highlighted a number of concerns and | would wish to take
the opportunity to address these in the order that they have been listed.

| have been assisted in the course of this by Matron Andrea Bliss and Mr Eki Emovon,
Clinical Director, Children and Family Care Group.

1. Poor communication on a number of levels

With respect to the discussion with the parents regarding a child’s clinical history, in
order to ensure better communication the team have reviewed the Paediatric IPOC.
Staff have been made aware of the need to listen to parents and take their views
into consideration when assessing the clinical picture in any child who is admitted.
Should children suffer from disabilities, medical and nursing staff will record, under
the respective part of the Paediatric IPOC, how such children are communicated with
and whether their disability further impedes their ability to communicate with
strangers and hence the need to have more detailed and in depth conversations with
parents. This situation will continue to pertain throughout the child’s stay in
hospital.

With respect to ineffective communication of microbiology results, the team has
considered the issue of outstanding test results and confirmed that during clinical
handovers the results should be accessed through ICE. Any outstanding matters will
form part of the documentation in the handover process in order to confirm that
they are followed up and acted upon. In respect of receipt of urgent blood results
from the laboratory via telephone, staff have been made aware that it is the
responsibility of the individual taking the call to record the results on the IPOC and to
verbally share the results with the medical staff as well as date, time and sign the
entry and record the member of medical staff that the results have been shared
with.

2. PAWS (Paediatric Advanced Warning Score)

Staff have been made aware that at the inquest it was highlighted there were a
number of poorly completed charts with incomplete scores during the episode of
care. It was the case that temperature readings had been recorded without a
corresponding record of the heart rate and respiratory rate being undertaken at the
same time which will enable significance to be attached to the result and correctly
identify scores. Any additional training needs for staff have been noted and are in
process of being addressed.

It is to be noted that all paediatric warning scores within the region are being
reviewed as part of the network of the Paediatric Operation and Delivery Network
led by the Network Clinical Educator and the team will ensure that any
developments with respect to PAWS will be filtered down to front line staff in order
to continue to maintain and accurate marker of the condition of a sick child.

3. Sepsis in Paediatrics

The inquest noted that there was lack of use of the sepsis tool kit and this is of
significant concern both to your office as well as the Trust. Since the outcome of the
inquest the Trust has worked rapidly to introduce such a tool based on the UK Sepsis
Trust tool to which there has been both nursing and medical contribution. | attach
the tool which has been agreed, implemented and disseminated in all the clinical

areas. Multi-disciplinary staff development will continue to provide training on
sepsis in children and unexpected deterioration in children. This training will include
medical staff on induction for each house.

Dissemination of key information and medical updates

The Trust has reviewed its systems for disseminating such information. The Sepsis
tool kit was disseminated and implemented for adults but for some reason this was
not achieved in paediatrics. The revised process involves such information being
received by the Patient Safety Review Group (PSRG) and then disseminated through
members of the group to the relevant areas where the information or update is
relevant. The PSRG will monitor that guidance has been implemented. The Trust
Sepsis Lead has undertaken to support the Paediatric team with monitoring of the
implementation of the Sepsis tool.

Poor record keeping

It is acknowledged that record keeping was poor both from medical and nursing staff
and | confirm the individuals who were involved in this case have reflected on this
and the importance of recording care that is given to patients. Staff have been
reminded that good record keeping is in line with what is expected by the Nursing
and Midwifery Council and the General Medical Council Guidelines on record
keeping. In respect of this all Consultants within the Trust are required to undertake
an audit of clinical records as part of their yearly appraisal.

You would be interested to note that there have been the following immediate changes to
practice:

i.

In all instances the minimum recording on PAWS includes temperature
measurement, pulse and heart rate measurement as well as frequency of
respirations. This is documented together with the child’s colour at the time that
such observations have been undertaken.

Any skin change such and pallor, mottling or rash is documented on the PAWS chart
and a minimum temperature pulse and respiratory rate performed at that particular
point in time.

The PAWS score is documented for each individual observation and then totalled.
Any observations will be documented directly onto the PAWS chart.

Staff have been made aware of these changes in practice and have been required to
complete a self-declaration form. This allows opportunity for individuals to inform
the Line Manager if they require additional training relating to observations and
PAWS. Each Healthcare Assistant is also asked to complete a self-declaration form
indicating that they were competent to undertake and document physiological
observations and to report to a Registered Nurse any observations/PAWS outside of
normal parameters. Each Registered Nurse has been asked to complete a self-

declaration to indicate that they were competent to undertake document and
interpret physiological observations and able to report to medical staff any
observations/PAWS outside of normal parameters.

| trust that this will provide assurance that appropriate action has been taken following the
death of Marc Jason Stephen Poole. The changes will continue to be monitored by the Care
Group Clinical Governance team and Patient Safety Review Group.

May | take this opportunity to invite you to revert back to me should you feel it necessary to
do so.

Yoursjsincerely
\ |

\ |

Deputy Medical Director - Clinical Standards

Doncaster and NHS]

Bassetlaw Hospitals

NHS Foundation Trust

Paediatric Sepsis Screening and Action Tool

Sepsis is a time critical condition. Screening, early intervention and immediate treatment save lives.
This tool should be applied to all children with suspected infection or who have observations outside normal limits.

1. Could this be an infection?

For example:

Pneumonia

Urinary Tract Infection

Abdominal pain or distension

Meningitis

Cellulitis/ septic arthritis/ infected wound

Y

Are any 2 Systemic inflammatory response
syndrome (SIRS) criteria present

2:
- Temperature > 38.5°C or < 36°C
_- Inappropriate tachycardia or bradycardia -
Altered mental status (including sleeping/
irritability/ lethargy/ floppiness

- Reduced peripheral perfusion/ prolonged
capillary refill/ reduced urine output or wet nappies.

r

(3. Is any one Red Flag present? an

- Hypotension

- Blood gas lactate > 4 mmol/|

- Capillary refill > 5 seconds

- Pale/ mottled/ ashen/ blue or non-blanching
rash

- Oxygen needed to maintain saturations >92%
- Respiratory rate > 60 min” or > 5 below the
normal, or grunting

-AVPU =V, PorU

- Parents report one of:

excessively dry nappies, lack of response to
social cues, significantly decreased activity, or
aul high-pitched or continuous cry i)

This tool is developed from original work
of the UK Sepsis Trust. The Paediatric
Sepsis Six and Paediatric Red Flag Sepsis
are the intellectual property of the UK
Sepsis Trust

SEPSIS
TRUST

Sepsis not present now:
Observe and review as per clinical
need.

| Sepsis considered

inform responsible clinician.

| Begin hourly observations.

Reassess for severe sepsis hourly.
Ensure FBC, CRP, U&E, LFT, BM,
venous blood gas with lactate & blood

cultures sent.

Monitor urine output.

| When to consider observations

abnormal:

Tachycardia

mA
nA

>110

Bradycardia Hypotension

systolic BP

O days to | week

<100

| week to | month

| month to | year

T3 to 18 years

NA

(Red Flag Sepsis
This is a time critical condition,

Take bloods as mentioned in the box
Sepsis considered. Assume severe
sepsis present.

Paediatric Sepsis Six:

1 High-flow oxygen.

2 Take cultures. glucose, FBC, lactate, CRP
3 Intravenous or intraosseous antibiotics

4 Fluid resuscitation (20ml/kg)

5 Involve senior clinicians early

6 Consider inotropic support early

Record the time each of these actions is
completed. All actions should be completed

as soon as possible but a/ways within 60
(minutes. oy