Sydney Neil

INHS)

|
|
| Birmingham South Central
| Clinical Commissioning Group

‘oe INVESTORS | ,
\, 2 IN PEOPLE

21° September 2016

Birmingham South Central CCG
Second Floor

Bartholomew House

142 Hagley Road

Mrs Louise Hunt

Senior Coroner

Birmingham & Solihull Districts Coroners Court
50 Newton Street

Birmingham, helo
B4 6NE
B16 9PA

0121 255 0700

Dear Mrs Hunt

Sydney Mya Neil (deceased)

Following receipt of your previous correspondence in respect of this unfortunate incident, the CCG has
reviewed the current GP contract, the national guidance and best practice available from the Care
Quality Commission (CQC), the General Practitioner’s Committee (GPC), the Local Medical Committee
and the Resuscitation Council (UK). The CCG view would be that the following would be the basic
equipment requirement for General Practice in relation to the management of cardiorespiratory arrest:

*List taken from the Resuscitation Council (UK) Equipment and drug lists - Primary Care - Minimum
suggested equipment.

Protective equipment - gloves, aprons, eye protection. .
Pocket mask (adult) with oxygen port (may be used inverted in infants).

Oxygen cylinder (with key where necessary).

Oxygen tubing.

Automated external defibrillator (AED) (Preferably with facilities for paediatric use as well as use in
adults).

Adhesive defibrillator pads (Spare set also recommended).

Razor.

Stethoscope.

Absorbent towel (To dry chest if necessary).

All organisations providing primary care should also have appropriate equipment and drugs for
managing other life-threatening emergencies (e.g. anaphylaxis). The CCG would expect all GP staff to be
trained to deliver basic CPR to patients, to have this training updated on a regular basis and have
appropriate protocols in place to deal with such emergencies. The CCG has a programme of contract
visits where we will ensure that practices are adhering to the guidance provided above Birmingham South Central

Clinical Commissioning Group

Tel: 0121 255 0863

Email: infobsc@nhs.net

Chair: Dr Andrew Coward

Vice-Chair: Denise Plumpton

Clinical Vice Chair: Dr Raj Ramachandram

In respect of suction being available, the CCG view would be that there would be no requirement for GP
practices to have suction available on a regular basis since the use of such equipment would be
extremely rare and it would be difficult for GPs to maintain their competence in using this type of
equipment. Similarly the CCG would not expect a GP to be able to intubate a patient or to have the
equipment available to undertake this procedure as this would not be within the regular skill set of a GP.
This view is based on the Resuscitation Council (UK) guidance that identifies these equipment and
competencies are required for GPs having an extended role in aspects such as urgent and emergency
care rather than generic general practice.

The CCG has been assisting the practice involved in this incident to identify and address issues that have
been highlighted by this unfortunate incident and it is the intention of the CCG to circulate any learning
from this incident across all GP practices that we are responsible for commissioning. We will also
circulate this learning to surrounding CCGs so that they may also disseminate these lessons to their
practices,

If you have any queries regarding the above please do not hesitate to call me or e-mail me.

Yours sincerely
Dd Naunr Rare,

= Accountable Officer

Birmingham South Central CCG

Birmingham South Central
Clinical Commissioning Group
Tel: 0121 255 0863

Email: infobsc@nhs.net

INHS|

England

Professor Sir Bruce Keogh

National Medical Director

Skipton House

=; 80 London Road
RECEIVED | SE1 6LH

-7 SEP

Mrs Louise Hunt

Senior Coroner for Birmingham and
Solihull

50 Newton Street

Birmingham

B4 6NE 5"" September 2016

Your ref: 113279 - SYDNEY MAY NEIL (LH/RP)

Dear Mrs Hunt,
Re: Regulation 28 - Sydney Mya Neil

Thank you for sharing a copy of your Regulation 28 report regarding the sad
death of Sydney Mya Neil.

This was a tragic case of a young girl, suffering from severe brittle asthma, who
suffered a severe exacerbation of her asthma at school. At the inquest, you
determined that there was ineffective ventilation due to the lack of available
oxygen and obstruction of her airways by vomit.

You have raised the following concern:-

1. The absence of either suction equipment or oxygen at Wychall Lane
Surgery which led to inadequate ventilator support being given for 8
minutes pending arrival of the ambulance service and the level of
expertise in GP practices when resuscitation is required and whether GP
surgeries are adequately equipped to deal with emergency situations.

Background

Asthma UK and other sources, suggest that up to 5.4 million people in the UK
are currently receiving treatment for asthma and it accounts for high numbers of
consultations in primary care, out-of-hours services and hospital emergency
departments.

During 2011-2, there were over 65,000 hospital admissions for asthma in the UK
and whilst the number of deaths from asthma is falling, the number of reported
asthma deaths in the UK remains amongst the highest in Europe

A National Review of Asthma Deaths (NRAD) was commissioned by the
Healthcare Quality Improvement Partnership (HQIP) on behalf of NHS England,
NHS Wales, the Health and Social Care division of the Scottish government, the
’ Department of Health, and the Northern Ireland Department of Health, Social

High quality care for all, now and for future generations

Services and Public Safety (DHSSPS).
Its report ‘Why asthma still kills’ was published in May 2014.

Key recommendations included the following.

e Better education is needed so that doctors, nurses and other healthcare
professionals are aware of factors that increase the risk of asthma attack
and death. :

e Every NHS hospital and general practice should have a designated,
named clinical lead for asthma services, responsible for formal training in
the management of acute asthma.

e Asthma patients prescribed more than 12 reliever inhalers in a year should
have an urgent review of their asthma control.

e Follow-up arrangements should be made after every attendance at an
emergency department for an asthma attack. After discharge from hospital
for asthma, patients should be followed up:in hospital outpatients.

e People with asthma should have a structured review by a doctor or an
asthma nurse with specialist training at least once a year.

e People with asthma should be provided with a personal asthma action.

plan (PAAP). This is a written record of the discussion that a patient has
with their GP or asthma nurse about their asthma care to help them
manage the condition.

Guidance

In England, a structured approach to the management of asthma is supported by
the Quality Outcome Framework, which incentivises practices to offer all patients
diagnosed with asthma an annual review.

The current guidelines for optimising asthma management are the 2014

guidelines published by the British Thoracic Society (BTS) and Scottish
Intercollegiate Guidelines Network (SIGN)

The ‘British guidelines on the management of asthma” highlights the challenges
of managing ‘brittle’ or ‘difficult’ asthma similar to Sydney's condition. The
guidance recommends that patients with difficult asthma should be jointly
managed with shared care arrangements between primary and secondary care.
Patients should be managed by a ‘personal asthma action plan’ and as
highlighted: in the NRAD report, in the case of such brittle disease this should
advise a patient in the event of an emergency situation to access secondary care
services directly.

The BTS/SIGN guidelines concur with your findings that supplementary oxygen
should be available in all health care settings including GP surgeries and states
that in addition, nebulisers for giving nebulised B2 agonists bronchodilators
should preferably be driven by oxygen.

1 SIGN 141 British Guideline on the Management of Asthma. October
2014

High quality care for all, now and for future generations

The Care Quality Commission (CQC) as the regulator of general practice needs
to be assured that practices are able to immediately respond to the needs of a
person who becomes seriously ill. The CQC does not have explicit guidance
around emergency equipment; however does state that if the practice does not
have oxygen they are unlikely to be able to demonstrate they are equipped for
dealing with emergencies.”

In determining what equipment and training a general practice should have, the
CQC will consider the individual circumstances of the practice such as the
practice’s ability to access emergency services in a timely manner. On this basis,
unless a practice is based in a particularly remote or inaccessible location,
practices should be able to rely on rapid access to emergency services when
planning what equipment and training is appropriate to meet the needs of
patients in primary care.

In relation to the requirement for suction facilities to facilitate ventilator support, |
have sought the views of NHS England’s National Clinical Directors. Whilst a
number of practices will have some access to suction facilities, it was not felt that
this should become a national requirement of primary care. BTS guidance
highlights the risks associated with ventilatory support and non-invasive
ventilation, (NIV) in severe asthma. It is the view of my Clinical Directors
therefore better to target training in primary care on recognising an emerging
emergency situation rather than to attempt to train and maintain skills in using
suction equipment in challenging emergency situations. As a result, | do not feel
it appropriate to mandate all general practices to purchase and maintain suction
facilities which would necessarily include ensuring all relevant staff are
appropriately trained.

Action

| agree that the key action that must arise from this tragic case is the need to
ensure that the health service doesn’t become complacent in its management of
asthma. The NRAD published in May 2014 has highlighted 6 key
recommendations which would make a difference to the numbers of people who
die each year because of their asthma. These recommendations have informed
the General practice Quality Outcome Framework, supporting individualised
personal asthma plans for asthmatic patients. It is recognised however that we
need to go further to embed these improvements into routine clinical practice.

The 2016 update to the BTS/SIGN asthma guidelines is due to be published in
the Autumn and | will use this as an opportunity to raise awareness of asthma
management in primary care. | will do this by communicating to all GP practices
through our GP Bulletin. | also intend to share this with the CCGs who
commission secondary care and emergency services.

| have asked I 4eac of Primary Care Commissioning, NHS

2 COC has published agreed principles for defibrillators oxygen and
oximeters and Cardiopulmonary Resuscitation in general practice.

High quality care for all, now and for future generations

England to write to Steve Field, CQC Chief Inspector for primary care, to ensure
the CQC through its inspection regime, ensures that primary care services carry
the necessary equipment and skills to address respiratory emergencies.

| hope the above has provided some reassurances that NHS England has taken
your concern on board.

Yours sincerely,

Zant \( - | |

Professor Sir Bruce Keogh KBE, MD, DSc, FRCS, FRCP
National Medical Director
NHS England

High quality care for all, now and for future generations

WYCHALL LANE

31-Aug-2016

Mrs Louise Hunt
HM Senior Coroner
Birmingham & Solihull Areas

Coroner’s Court -7 SEP 9

50 Newton Street

11 Wychall Lane
Kings Norton
Birmingham

B38 8TE

Tel: 0121 628 2345

Fax No: 0121 628 8282
Website: www.wychalllanesurgery.co.uk

Birmingham Sse ssewss-}

B4 6NE

Dear Mrs Hunt

Re: ee me Neil DOB: 21-Oct-2004 (Deceased 06-Mar-2016)

1am writing in response to your REGULATION 28 REPORT TO PREVENT FUTURE
DEATHS relating to the inquest on 15" july 2016 into the death of Sydney Mya Neil.

| will address your concerns regarding the use of suction, oxygen, the level of
expertise in GP practices and the availability of equipment to deal with emergency
situations.

Following the initial SUDIC case discussion on 10" March 2016 recommendations
from respiratory consultant at Birmingham Children’s Hospital, namely
to have continual oxygen saturation readings while nebulising a child, have been
incorporated into our protocol for Acute Asthma Management in children. Oxygen is
used to nebulise should the oxygen saturation fall below 94% in air (attachment 1).

Following the SUDIC meeting in March the practice carried out a serious case review
(attachment 2). The outcomes obtained from this review have all been incorporated
into our emergency protocol.

| have obtained advice regarding resuscitation in General Practice.
The Care Quality Commission has recommendations for cardiopulmonary

resuscitation (CPR) in GP practices. It states all GP practices must be equipped to
deal with a medical emergency and all staff should be suitably trained.

There should be a named resuscitation lead in GP practices (Dr Mathias Sander) to
ensure:

1-The practice has access to resuscitation advice, training and practice.
2 - Quality standards are maintained.
3 - Basic checks of equipment.

It suggests agreed principles for defibrillators, oxygen and oximeters (attachment 3).
We have these at the practice.

The CQC also promote the Resuscitation Council UK’s list of minimum suggested
equipment to support CPR in primary care settings. | enclose a list that the
Resuscitation Council suggest (attachment 4). | can confirm the practice has the
equipment suggested in place.

We have met with Birmingham South Central CCG and after a detailed significant
event analysis they have stated:-

“All organisations providing primary care should also have appropriate equipment
and drugs for managing other life-threatening emergencies (e.g. anaphylaxis). The
CCG would expect all staff to be trained to deliver basic CPR to patients, to have this
training updated on a regular basis and have appropriate protocols in place to deal
with such emergencies. In respect of suction being available, the CCG view would
be that there would be no requirement for GP practices to have suction available
on a regular basis as the use of such equipment would be extremely rare and it
would be difficult for GPs to maintain their competence in using this type of
equipment. Similarly the CCG would not expect a GP to be able to intubate a
patient or to have the equipment available to undertake this procedure as this
would not be within the regular skill set of a GP. This view is based on the
Resuscitation Council (UK) guidance that identifies these equipment and
competencies are required for GPs with an extended role in aspects such as urgent
and emergency care rather than generic general practice” (attachment 5).

| understand the CCG will be providing its own response to the Regulation 28 Report.

We have taken advice from the Local Medical Committee and General Practice
Committee (GPC) of the BMA who commissioned who is a senior GP who
has held roles including provision of and teaching of immediate care, now known as
Pre-Hospital Emergency Medicine and is chair of BASICS Education Ltd, who aim to
improve emergency care outside hospital, to comment on the care the Practice
provided to Miss Neil and provide his general thoughts on this incident. He states
general practice and general practitioners are not an emergency service......
General practitioners who very, very infrequently have to deal with life
threatening emergencies and are neither equipped, contracted nor organised to
deliver such team based emergency care.

Once the problems of skill decay are incorporated into the mix then a decision has
to be made on a professional cost benefit analysis of whether it is more
appropriate and beneficial to use scarce GP resources being spent repeatedly re-

training for something that they might do once or twice in a lifetime when there is
supposed to be paramedic with an assistant, the equipment and an ambulance
available within eight minutes better able because of psycho motor freshness to
deliver a positive outcome by slick delivery of technical skills (attachment 6).

Consultant respiratory paediatrician commented at the inquest (taken from
the transcript):-

When you reach the point of cardiac arrest the medicines - you are unable to get the
medicine through the normal mechanism of breathing into the lungs. The only
effective way of getting medicine in is through a drip; that needs to be in hospital...
even in this scenario when we are at that stage of a cardiac arrest, even if we had
performed the resuscitation with a clear airway, the chance of being able to drive
oxygen down inside into the lungs properly would have been very difficult.

The Royal College of General Practitioner’s Mapping of Quality Standard Indicators
(2014) states that for Practice Accreditation (PA) “The provider operates a system to
ensure that an appropriate healthcare professional can be contacted promptly in the
case of emergency.”

Also, “All first contact team members have been trained to recognise and respond
appropriately to urgent medical matters. A first contact team member trained to
recognise and respond appropriately for basic life support is always available (The
Duty Doctor)”.

Our practice has this in place.

The Practice has reflected carefully on this incident, and has noted your concerns in
your Regulation 28 Report. The Practice has consulted widely to obtain a range of
opinion both on the care the Practice provided to Miss Neil, as well as what changes
we need to implement to provide an appropriate level of management in a primary
care setting so as to ensure patient safety. We believe the steps taken, as noted
above, and as directed by experts in the field as well as Organisations overseeing
patient care and safety, demonstrate the Practice’s due regard of your concerns as
well as evidence of our intentions always to provide the best care for our patients.

Assuring you of our full co-operation,

Yours sincerely

MBBS MRCGP