Johan Pambou

England
Professor Sir Bruce Keogh
National Medical Director
Skipton House
80 London Road
Mrs Louise Hunt SE1 6LH
HM Senior Coroner
Birmingham & Solihull Districts
50 Newton Street XB: June 2017
Birmingham
B46NE

Dear Mrs Hunt
Re: Johan Stone Pambou (deceased)

Thank you for agreeing to an extension of time for us to respond to your
Regulation 28 Report into the tragic death of Johan Pambou. | would like to
express my deep sympathy to Mr Pambou’s family.

In this letter | outline-the actions that have been taken and proposals for next
steps. :

In your report you identified two main matters of concern.

1. Systems and record keeping in the GP practice. Four letters were
received asking for this child to receive pneumovax23 vaccination from
February 2016 to November 2016. None of these letters were actioned by
the GP. You raised concern that there was no adequate system in place to
monitor and act on letters received from hospitals which means other
essential treatment may be missed for other patients.

2. Availability of pneumovax vaccine 23. You heard evidence from the GP
in this case that attempts were made to obtain the vaccine in June 2016
but it was unavailable. You were advised that the vaccine continues to be
unavailable, raising concern that GPs will not be aware where to access
the vaccine.

To inform our response, we have engaged with Public Health England and Merck
Sharp & Dohme (MSD) the manufacturers of the Pneumococcal Polysaccharide
vaccine (Pneumovax) over the issue of availability of the pneumovax vaccine 23.
In addition, a serious incident group has been established which has met on 22
May 2017 and 9 June to discuss the local issues relating to the care provided to
Johan Pambou at his general practice.
The serious incident group representatives include;
e Dr Dhamija and the practice manager from the GP practice — Lea Village
Surgery
e Screening & Immunisation lead and manager (Public Health England,
West Midlands)
e NHS England Quality lead (West Midland)

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e Birmingham Cross-City Clinical Commissioning Group (CCG)

e The Clinical Governance lead for the Midland Medical Partnership

e Consultant paediatric haematologist — Birmingham Children’s Hospital
(BCH)

The outcome of the serious incident process is to establish a root cause analysis
(RCA) and to identify learning that can inform actions which can be taken locally
to improve safety as well as to inform wider learning which can be shared across
NHS England.

Systems and record keeping in the GP practice.

Your Regulation 28 Report identified deficiencies in how communication from
Birmingham Children’s Hospital had been actioned by the GP practice.

Once a patient with sickle cell disease reaches the age of 2 years of age they
should receive a single dose.of Polysaccharide Pneumococcal Vaccine (PPV).
BCH routinely request this for affected patients from their GP Practice. Sickle cell
patients would then need subsequent PPV immunisation every 5 years.

NHS England commissions a national PPV enhanced service which requires
participating practices to identify and offer PPV to eligible patients through a
‘proactive call and recall basis.’ The enhanced service requires practices to have
a system for identifying and calling / recalling at risk individuals which should
occur independent of any letter from specialist services. :

Lea Village Surgery had signed up to deliver the PPV enhanced service, however
the significant incident review identified that there was poor record keeping in the
practice with no documentation that the requested action in the February and
March letters were undertaken on receipt of the letters. This falls short of the
expectations of a practice providing this service and the commissioning team will
consider what contractual action should be taken in the circumstances.

In June 2016, prompted by a conversation with Johan’s parents, the practice
state that they had sought advice from the community specialist nurse about the
appropriate vaccine.

The serious incident review has identified confusion over terminology regarding
the name of the appropriate vaccine. Communication between the practice nurse
and the community specialist nurse failed to establish that ‘Polysaccharide
Pneumococcal Vaccine’ (which the practice had in stock) was the same vaccine
as ‘Pneumovax23’ which was the recommendation from BCH.

The Incident group has found that the systems and processes governing patient
related communication at the Lea Village surgery was poor, however, since the
inquest, the practice has merged to become a member of the Midland Medical
Partnership (MMP). At the time of the merge, MMP were not aware of the
findings at inquest.

The Incident group have received assurances that MMP have undertaken a
thorough review of Lea Village Surgery’s systems and processes. The review
has established that PPV was likely to have been available at the practice in
June 2016 and further stocks were received in October 2016.

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An action plan has been developed and implemented by MMP which has
included the setting up of regular dedicated immunisation clinics and a recent
audit has demonstrated robust electronic recording of actions from hospital
letters.

Availability of pneumovax vaccine 23

Although you heard at inquest that attempts were made to obtain the vaccine in
June 2016 but it was unavailable, findings from the serious incident meeting have
subsequently shown this to have been mistaken.

This has been supported by our inquiry of MSD who have confirmed that whilst
there had been some intermittent interruptions in the availability of PPV vaccine
between September 16 until the end of the year, there had been no interruptions
in vaccine availability between January and September.

Many vaccines have supply issues from time to time as they are a biological
products that can take a long time to manufacture and can fail quality testing and
are influenced by worldwide demand/supply issues

GP practices are kept up to date with vaccine supply issues through a publication
‘Vaccine Update’ which is the monthly PHE publication for anyone involved in
delivering immunisations https://Awww.gov.uk/government/collections/vaccine-
update. Public Health England (PHE) informs commissioners via the National
Immunisation Network (scheduled every 2 weeks) of vaccine supply problems
with instruction to cascade to local providers what action to take and which
cohorts of patients should be prioritised. PHE also alerts providers via notification
on the ImmForm ordering and data collection system of supply problems.

Further clinical advice is available from the screening and immunisation team
(SIT) via england.wmid-imms@nhs.net — the team can signpost to any national
guidance on prioritisation of patients during a period of vaccine shortage.

Despite these systems, the system broke down in relation to the care offered to
Johan Pambou. It is evident that this was not due to a vaccine supply shortage
but in part caused by confusion over vaccine nomenclature. NHS England will
write to Public Health England to inform them of this incident so that they can
include the learning in their planning for further communication with front line
staff. We are aware that PHE is considering further means by which
communication with practices can be enhanced by developing a regional or
national cascade.

Next steps

Whilst the serious incident review process is not yet complete, it has identified a
number of issues which need to be addressed locally and which need to be
disseminated more widely so that lessons can be learnt.

These are:
1. The need for adequate coding of significant disease to allow robust follow
up and recall :

2. The need for a robust system in general practice to ensure actions
requested by outside parties are managed
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3. Ensuring practices are aware of the escalation process if there are issues
with availability of vaccinations.

In addition, there is a need to establish how a provider like a Trust (in this case
Birmingham Children’s Hospital) escalates a concern if they become aware that
a required action is not being addressed by a patient's GP.

A letter to GPs has been developed and shared with Local Medical Committee
(LMC) for comment prior to dissemination to all local GPs by the regional Medical
Director, Dr Kiran Patel. The LMC has also contacted all practices on 15 June to
reinforce the responsibilities and actions required at practice level in compliance
with the enhanced service.

The letter will be shared with all regional medical directors in NHS England for
onward circulation to ensure there is national sharing of these learning points.
The incident group is next meeting on June 29 and will continue to oversee the
process to establish effective systems and processes at the Lea Village Surgery
site so that NHS England can be confident.that the practice is providing safe and
effective care.

Contractual or regulatory issues will be addressed by the relevant teams within
NHS England and the commissioning CCG.

| can confirm that NHS England has convened a Performance Advisory Group to
consider the issues and the roguiatory process is underway to address capability
and conduct issues of the GP.

Summary

This is a tragic case of what could have been a preventable death of a young
child. We are taking action to ensure individuals and the wider system, learn the
lessons of how such deaths could in the future be prevented.

Thank you for raising these issues through the formal processes, | hope | have
been able to reassure you that whilst your concerns were well founded. NHS
England is taking action to address the risks of such an event occurring again in
the future. .

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

High quality care for all, now and for future generations