Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0243, written 1 Sep 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 Sep 2017 |
|---|---|
| Reference | 2017-0243 |
| Deceased | Mohammad Ashraf |
| Coroner | Louise Hunt |
| Coroner area | Birmingham and Solihull |
| Category | Child Death (from 2015) · Community health care and emergency services related deaths · Other related deaths |
| Organisation named | Birmingham Community Healthcare NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Caterlink 2. Birmingham City Council 3. AlHijrah School 4. Birmingham Community Healthcare NHS Trust CORONER tam Louise Hunt Senior Coroner for Birmingham and Solihull CORONER’S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (investigations) Regulations 2013. INVESTIGATION and INQUEST On 30/03/2017 | commenced an investigation into the death of Mohammad Ismaeel Ashraf. The investigation concluded at the end of an inquest on 24th August 2017. The conclusion of the Jury at the inquest was: . “Ismaeel died from an anaphylactic reaction to an undetermined allergen. This is likely to be something he ate. Central issue to the case, we consider to be: 1. There was a failure to recognise the importance of the care plan, and to follow it. 2. The delay in finding and administering the epipen was significant and contributed to his death. This death was contributed to by neglect.” CIRCUMSTANCES OF THE DEATH The deceased was a 9 year old boy who attended Al Hijrah school. He had a number of allergies which included dairy, nuts and kiwi and possibly fish. He had a care plan in place at school which specified what his allergies were and what treatment was to be provided in the event of a severe allergic reaction. This amounted to piriton for minor symptoms and an epipen in the case of a severe reaction. The epipen was stored in his school classroom. The care plan was clear in stating that the treatment should be brought to the child. On 03/03/17 Ismaeel had lunch at 12.33pm which was fish fingers, chips and peas or beans with a capri sun drink — he then went to play and came back to his class at 1.00pm for a maths lesson. At around 1.45pm he complained of stomach ache — a minor symptom of an allergic reaction on his care plan. His teacher thought he was having an allergic reaction to the fish he had ate at lunch. His care plan said he was allergic to fish. He was sent to reception without a staff member where he was given piriton by one of the reception staff. He returned to the class room just before 2.00pm. At this time the children were lining up for prayers. lsmaeel asked to use his inhaler. His breathing was said to be heavier. The teaching assistant said for him to use his inhaler and then told the teacher. The teacher took him to reception where he left Ismaeel with the reception staff and another teaching assistant from a different class before going to prayers. An ambulance was called at this time by the reception staff. Whilst in reception the CCTV shows him deteriorating over a 15 minute period. At one point he states to staff that he thinks he is going to die. Despite this he did not receive his epipen injection as specified in his care plan. An ambulance arrived at 14.13 and administered the epipen which staff had previously had difficulty finding. Despite treatment Ismaeel went into cardiac arrest and attempts to resuscitate him were unsuccessful resulting in his death later that day at Birmingham Heartlands Hospital. Following a post mortem, the medical cause of death was determined to be: ANAPHYLACTIC REACTION CAUSED BY AN UNDETERMINED ALLERGEN CORONER’S CONCERNS 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. That care plans are not in place for all pupils that require them. Evidence was heard at the Inquest that the deceased's sister’s care plan is still inaccurate, despite this having been identified to the school. 2. That there are delays in issuing care plans. Care plans need to be issued quickly where a child has an allergy. 3. All issued care plans had not been provided to Caterlink by the school and communication between the school and Caterlink was not as effective as they could be. 4. Asan interim measure lanyards had been used to try and identify which food children were allergic to when buying their lunch. The Inquest heard how some lanyards were not accurate and lanyards themselves are not safe as they may be amended or worn by a different pupil. 5. Immediately following this tragic event, the Local Authority procured a report to look at the safety of food delivery in the school. That report identified a number of matters requiring attention which included identifying that the lanyard system that the school had introduced as an interim measure was not safe. This recommendation and others were not communicated to the school or anyone else, to enable them to make essential changes to processes to ensure the management of children with food allergies was adequate. | am therefore concerned that the local authority has no process in place to ensure that recommendations are immediately communicated to those affected by them so that practices can be changed and processes put in place to rectify the problem. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 27" October 2017. |, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the family and to the local Safeguarding Board. | have also sent a copy to the Anaphylaxis association who may find it of interest. | am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 01/09/2017 Signature. \ Louise Hunt Senior Coroner Birmingham and Solihull
2 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Al-Hijrah School An tslamiec through school providing g a il dt jenn education for children aged 4-16 The Cherrywood Centre Burbridge Road Bordesley Green Birmingham B9 4US HM Senior Coroner for Birmingham and Solihull Louise Hunt HM Coroner’s Court 50 Newton Street Birmingham B4 6NE Friday 27 October 2017 By Special Delivery and Email Email: lynne.boyle@birmingham.gov.uk coroner@birmingham.gov.uk Dear Ms Hunt Inquest touching the death of Mohammad Ismaeel Ashraf | thank you for your email of 1 September enclosing a Regulation 28 Report following your Inquest into the death of Mohammad Ismaeel Ashraf. | have carefully reviewed the PFD and as you know | was in attendance throughout the inquest and heard all of the evidence given to the court. | am grateful to you for providing Al-Hijrah School (the “School”) with the opportunity to respond to the concerns you have identified in the report. | have liaised with Birmingham Community Healthcare NHS Foundation Trust (“Trust”) and where relevant | have included information to address the concerns you have raised in relation Al-Hijrah School | #4!) 44s yr» to the Care Plans, your concern number 2 in the PFD, and this letter forms a joint response from the School and the Trust. If | can summarise the concerns that you have, which may relate to the School, are numbered 1, 3, 4. and 5. We will provide some information in relation to concern number 2 of the report relating to the delay in issuing the Health Care Plans. 1, That care plans are not in place for all pupils that require them. Evidence was heard at the inquest that the deceased’s sister’s care plan is still inaccurate, despite this being identified to the school. The School was very concerned to hear the evidence given by the uncle of the deceased at the inquest that the Health Care Plan for Ismaeel’s sister was inaccurate. At the time of the inquest the pupils were on the six week summer holiday and so neither this pupil nor any other pupils were being put at risk at the time the evidence came to light. The School took immediate steps, before the school re-opened in September 2017, to review and rectify any inaccuracies. The School has collated all existing Health Care Plans and have now produced the most up-to-date Health Care Plans for each pupil that is known to have an allergy. All information, regarding pupils medical needs, have now been cross referenced against the School’s master Health Care Plan records, the School’s Management Information System (MIS) and against the records of the Trust (with the School’s Nurse). All Health Care Plans were dated at the beginning of the autumn 2017 term. All up-to-date Health Care Plans that have been transferred to the catering staff have been signed and dated to avoid any ambiguity. The review that was carried out by the external professionals (Peacocks Education Birmingham - City Council, OFSTED, Jon Needham - Birmingham Safeguarding Lead, Southalls - Leading Health and Safety Consultants specialising in food safety legislation) ensured that a complete, thorough and robust audit was undertaken to ensure the accuracy of the information the school holds regarding Health Care Plans and all other medical matters in supporting pupils with medical needs in school. The School has implemented a routine half termly check of all Health Care Plans displayed in key locations and held by the catering teams, which are cross checked against the master list held centrally at the School. Belief | Education | Excellence G98 | aaled | Ole! Al-Hijrah School | @y>¢!! 4u ja All notifications made to the School regarding a pupil’s medical condition, including allergies, must be provided by the parent/guardian to the School in writing using the data information sheet. The data information sheet must be signed by a parent/guardian of the pupil and counter signed by the staff member at the School accepting the document. The documents are handed into the School office at reception. The written notification ensures that an accurate record is made of a pupil’s medical condition, before a referral is made to the Birmingham Health Care Trust, who will issue a Health Care Plan if required. The office immediately notifies the SENCO (Special Education Needs Coordinator) of any new medical conditions or any reported changes to a pupil’s medical condition. A copy of the data information sheet is provided to the SENCO and a copy kept in the School office. The SENCO signs to acknowledge receipt of the notification and immediately carries out a referral to the School nurse who is responsible for producing a Health Care Plan. The School has established a Central Medical Register which provides instant access to the status of a pupil’s Care Plan, all medication issued to a pupil and the location of the medicine. The Central Medical Register provides instant information to highlight any outstanding issues and the actions that are yet to be completed, including receipt of the Health Care Plan. The School will continue with its policy, as it has for many years, to send the existing medical details (including allergy details) out to every parent at the end of the school year. The information is sent to the parents for them to check and report back any changes at the start of the new academic year. The School now requests parental updates once a term in additional to the annual requests. A fortnightly newsletter includes a reminder about medicines and medical conditions. A reminder of the importance of updating the School of any new medical conditions or changes in a pupil’s medical condition is also on the opening page of the School’s website. 2. That there are delays in issuing care plans for all pupils that require them. Care Plans need to be issued quickly where a child has an allergy. The School is not responsible for issuing a pupil’s Health Care Plan. The School nurse employed by the Trust is the person responsible for issuing the Health Care Plans. The School immediately informs the School nurse of the pupil’s medical condition. The School nurse will then issue the pupil’s Health Care Plan, within seven days. It is not Belief | Education | Excellence G98 | aed | Gla ah School | # ysl! 4x jas always possible for the School nurse to issue the Health Care Plan within seven days if she has been unable to make contact with the family but a Health Care Plan is usually issued within that seven day timeframe. The Trust’s School nurse has weekly contact with the School during term time. The School nurse will make contact with the pupil’s family to verify the information provided in the notification and check that all identifiable symptoms and medication have been addressed, before issuing the final Health Care Plan, Additionally, any new pupil diagnoses of allergy requiring treatment or intervention are notified directly to a Trust inbox from the acute Trust which triggers the School nurse making contact with the family to ascertain full details before issuing a new Health Care Plan for that pupil. All medical notifications, including allergies, are accepted at the point the pupil’s parent provides written notification to the School. The catering team are immediately notified of any allergies through a meeting with the School’s Business Manager, where documents are signed and dated to ensure there is a record that the information has been shared. Pupils are then added to the list of pupil’s who must pre-order lunch and be accompanied by a member of school staff to lunch. Once received the Health Care Plan is to be issued to the catering team, the pupil’s classroom teacher and held at key locations around the School, immediately. If the School receives notification that a pupil is no longer allergic to a food that update is provided to the School nurse who will check the information provided before updating the Health Care Plan. In the interim, whilst the School awaits the revised Health Care Plan, the pupil is still identified as having that allergy. 3. All issued care plans had not been provided to Caterlink by the school and communication between the school and Caterlink was not as effective as they could be. Caterlink are no longer the catering providers at the School. The School now directly employs the catering staff who were previously engaged by Caterlink. The individual catering staff know the School and the pupil’s with allergies well. The School was delighted to be able to retain the individual catering staff members and to welcome them as employees. Belief | Education | Excellence G3 | pd | cle Al-Hijrah School | ® ps4} Aus p22 The School is now able to oversee and monitor the training delivered to the catering staff. All catering staff now attend the relevant continual professional development programme of training on a mandatory basis as employees of the School. In order to ensure that the School and the catering staff have access to relevant and specific food safety expertise the School has engaged Cityserve. Cityserve provides services that include management support, procurement of ingredients, menu development at the School, health and food safety inspections and food safety training to the School’s catering employees. Cityserve formally entered into an agreement with the School to provide these services, which includes regular on site attendance at the School, on Monday 9 October 2017. A monthly meeting now takes place between the School and the catering manager. The School keeps minutes of the monthly meetings. The meetings are used as forum to raise issues and concerns and to share information and updates. Aside from the regular monthly meetings the School has implemented a robust system to ensure that the catering staff are notified of any new allergy information as soon as the School is notified. The pupil is added to the pre-order list and a pre-prepared lunch is provided to the pupil by the catering team. The pupil is accompanied to lunch by a member of staff. A record is kept of all notifications made to the catering team and once a Health Care Plan has been issued by the School nurse a copy is immediately issued to the catering manager and a signed record kept of delivery and receipt of the Health Care Plan to the catering manager. As indicated in response to item 1, above, the Health Care Plans held by the catering team are physically checked against the Master list each half term. 4. As an interim measure lanyards had been used to try and identify which food children were allergic to when buying their lunch. The Inquest heard how some lanyards were not accurate and lanyards themselves are not safe as they may be amended or worn by a different pupil. It was my evidence to the inquest that | was not satisfied that the use of lanyards provided a robust protection for pupils’ at the school who we knew or suspected had allergies. It was always my view, and remains my view, that the catering team must also receive a pupil’s Health Care Plan and to review and be familiar with those plans. It was always my intention to use lanyards only as an interim measure and in addition to other systems. Belief | Education | Excellence Al-Hijrah School | §s¢l) 4s 520 In addition to the use of lanyards a flag to alert catering staff operating the tills in the School canteen was introduced on the tills from March 2017 to the end of the summer 2017 term. It alerted staff to the fact that the pupil had an allergy but it did not link to the School’s MIS data to notify the details of the pupil’s allergies. Since the Inquest additional, permanent, changes to the way we manage allergy risks during the lunchtime service have been implemented. All pupils with Health Care Plans for allergies, primary and secondary ages, place an order for lunch each day. The order list contains the relevant allergy information for each pupil against which the meals are provided. The food orders are coordinated by designated school staff and sent by the Business Manager to the catering manager before 10am each day. All meals for pupils with allergies are pre-prepared by the catering staff in the morning. All pupils with allergies are accompanied to lunch by a member of staff, including secondary pupils. The School began discussions with the provider of the till (Point of Sale) interface software to implement a system that allows the School to automatically pull the allergy information from the School’s MIS system straight to the till. The provider has only just released a software update to allow the MIS to interface with the till. The software update has been uploaded and is now operating at the School. Immediately following this tragic event, the Local Authority procured a report to look at the safety of food delivery in the school. That report identified a number of matters requiring attention which included identifying that the lanyard system that sn the school had introduced as an interim measure was not safe. This recommendation and others were not communicated to the school or anyone else, to enable them to make essential changes to processes to ensure the management of children with food allergies was adequate. | am therefore concerned that the local authority has no process in place to ensure that the recommendations are immediately communicated to those affected by them so that practices can be changed and processes put in place to rectify the problem Belief | Education | Excellence Gi | pale | Ola! ah School | @yp¢l! Aue jae The School had made numerous requests to the Local Authority to be provided with a copy of the draft report, following the visit in March 2017 and before the start of the inquest. The School received the draft copy at the same time as the Coroner, part way through the inquest. As soon as the School received a copy of the draft report it was reviewed by the senior leadership team at the School and an action plan drawn up to ensure all the report’s recommendations were implemented. The School received a revised final report from the local authority on 19 September 2017 which added two further recommendations, 13 and 14. | have enclosed a copy of the Action Plan, DOC ONE. | can confirm that all 14 recommendations have been implemented. The Action Plan is colour coded: green indicates the recommendation which have been implemented and amber indicates recommendations which have been implemented but which also have to be reviewed on an ongoing basis. | have not rehearsed in detail all the steps taken by the School in response to the recommendations but the enclosed Action Plan clearly demonstrates the steps taken by the School. The Safeguarding Lead from the Local Authority has undertaken a comprehensive review of the School’s policies and procedures managing medicines and medical conditions, since the conclusion of the inquest, and has declared that the School has taken its work very seriously and has put processes in place to effectively manage the risk. As well as the recent audit by the local authority Safeguarding Lead the School has also been subject to a recent, October 2017, monitoring visit by OFSTED. The School is awaiting the written report form OFSTED but the verbal feedback the School received from the two Inspectors was very positive and confirmed that significant improvements had now been implemented to ensure the safety of all the School’s pupils. The School has also engaged a food safety consultancy to undertake a further review of the systems and procedures in place to manage medicines and medical conditions. The consultants are former environmental health officers with a wealth of experience in food safety and systems to manage allergen risks. They have produced procedure documents on 9 separate issues: - Procedure 1: Receiving and Handling Medical Information. Belief | Education | Excellence G9 | ede | Oley! Procedure 2: Storage and Handling of Medicines. Procedure 3: Administering Medication Procedure 4: Medical Records and Consent Procedure 5: Compiling Individual Health Care Plans (IHCP’s) Procedure 6: Emergency Procedures Procedure 7: Lunchtime Procedures Procedure 8: Medical Training Procedure 9: School Trips/ Excursions and Sporting Activities. | have enclosed examples of the Procedure Documents, 1, 2 and 6, DOC 2. The Procedures capture the systems that are already operating at the School to manage medicines and medical needs. The Consultants have simply produced these helpful documents so that we can simplify how we share this information with the School staff. The relevant documents will be issued to all relevant staff at the beginning of the next term, and included as part of the School’s programme of continuing professional development training. The Procedure Documents do not replace the relevant detailed School policies including: Safeguarding, Health and Safety, Supporting Pupils with Medical Needs; and Medical Practice and Procedures. All these policies were reviewed during the autumn half term in 2017 and will be reviewed annually and as and when necessary. At the beginning of the Autumn Term 2017 all staff received training on how to manage the medical needs of pupils. The training included scenario based training to actively engage staff in working through a range of scenarios to ensure that they fully understood the School’s policies and their duties and responsibilities in a medical situation. | appointed a member of my senior leadership team to drive this programme of review and implementation. He has provided me with regular and detailed update reports on the implementation of the actions identified from the local authority commissioned safeguarding report. He has taken clear and decisive ownership of managing and delivering the changes and | am completely confident that the systems now in place to manage all the medical needs of the School’s pupils is as robust as it can be. The lessons that have been learnt from this tragedy will not stop now that all recommendations have been implemented. The programme of continual engagement with the pupil’s and their parents and the ongoing training the School provides to all staff will be the School’s legacy to Ismaeel and his family. h School | & ya! 4s p20 Belief | Education | Excellence Gs | aed | Ole! jrah School | § yagi 4 yao ormation that is shared with you in this formal If you have any questions arising from th response to the report please do not hesitate to contact me. Yours faithfully Head Teacher For and on behalf of Al Hijrah School Enc DOC ONE: Action Plan DOC TWO: Procedure Documents Cc cormeammu rr Legal Services Manager, Birmingham Community Healthcare NHS oundation Trust (Email Only) Belief | Education | Excellence Gsii | aalei | Ula!
Sent by email only: coroner@birmingham.gov.uk 27 October 2017 Mrs Louise Hunt HM Senior Coroner for Birmingham and Solihull Coroner’s Court 50 Newton Street Birmingham B4 6NE Your ref: 118485 Dear Mrs Hunt Legal Services Birmingham Community Healthcare NHS Foundation Trust 3 Priestley Wharf 20 Holt St Birmingham B7 4BN Tel: 0121 466 7033 Fax: 0121 466 7001 Mohammad Ismaeel Ashraf – Prevention of Future Deaths report – Regulation 29 response I write with regard to your Prevention of Future Deaths report dated 1 September 2017. I can confirm that the Trust has worked with Al-Hijrah school to provide you with a full response and our comments have been incorporated into their letter for your attention. Within that letter, the Trust has responded to your matter of concern no.2 in your PFD report. If you have any queries arising from the Trust’s input into the joint response please do not hesitate to contact me. Yours sincerely Legal Services Manager CC
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