Lauren Sandell

INHS EW, 0)

EAR
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England = 28

Ss
HS
18

Professor Stephen Powis
National Medical Director
Skipton House

80 London Road

SE1 6LH

Miss N Persaud

Senior Coroner

Walthamstow Coroners Court

Queens Road

Walthamstow

E17 8QP 1* October 2018

Dear Miss Persaud,

Regulation 28 Report to Prevent Future Deaths - Lauren Amelia Rose
Sandell

Further to the letter dated 24 August 2018, and your conversation with my
colleague in the central Public Health Commissioning team. | write to clarify how
the Child Health Information Services (CHIS) work with GP practice to support
the call and recall processes, and to highlight what improvements have been
made since 2016 to reduce the risks and prevent harm.

Public Heath England (PHE) and NHS England Public Health Commissioning
teams have the responsibility to monitor the uptake of Men ACWY, as part of
NHS England’s accountabilities as the commissioner of immunisation services.
In turn the local commissioning team alert practices to any poor uptake of
immunisation programmes. As outlined in our previous correspondence the
CHIS service is a key organisation locally that records whether or not a child/
young person has received a vaccine or other public health interventions. In
London the specific activities to improve services include sharing the guidance
algorithm “Pathway for Administration of HPV, Men ACWY and Teenage 3-in-1
Booster (Td/IPV)’. The document outlines when and where adolescent
vaccinations are offered and when general practice is to offer the vaccination.
The NHS England London Immunisations webpage has been amended to
include reference to the specific guidance. In addition, the London team, as part
of their general drive to improve the quality of services, undertook a region wide
audit of call/recall systems for vaccinations in 2016, and a research study looking
at factors affecting uptake of Men ACWY in general practice. The outcome of
the audit and research project has informed the local action plan to improve
services and has informed commissioning. NHS England immunisation
commissioners are working with NHS Clinical Commissioning Groups (CCG) to
ensure call recall systems are embedded in practice systems. In 2017, the
London CHIS services launched a new service providing electronic record of a

High quality care for all, now and for future generations

child’s public health interventions, replacing 18 different child health records
departments using 18 separate IT solutions in line with the new child health

digital strategy.

All regions across England are working to improve their CHIS services, to take
advantage of the emerging new technologies, and the output from the NHS
strategy for IT, reducing the risk of children who are eligible being missed from
call/ recall activity led by GP practice.

The sad death of Lauren has highlighted the importance of ensuring all aspects
of the vaccination service are improved for young people and their families, and
NHS England on a national basis is working to implement change to reduce
risks.

If you have any other areas of clarification, please do not hesitate to contact me.
Yours sincerely,

Professor Stephen Powis
National Medical Director
NHS England

High quality care for all, now and for future generations

INHS i, 1)

YEARS
England = t"8
Professor Stephen Powis
National Medical Director
Skipton House

80 London Road

Miss N Persaud SE1 6LH
Senior Coroner

Walthamstow Coroners Court

Queens Road

Walthamstow »
E17 8QP 24" August 2018

Dear Miss Persaud
Regulation 28 Report to Prevent Future Deaths - Lauren Amelia Rose Sandell

Thank you for your regulation 28 report dated 25 June 2018 concerning the death of
Lauren Sandell on 2 October 2016. | would like to reiterate our condolences to Lauren’s
family.

| accept the narrative conclusion of the inquest being that Lauren’s death was avoidable,
as a result of the GP practice not implementing the Men ACWY immunisation
programme to all of the requirements of the enhanced service specification.

We are very sorry about this and our primary care team in London is working directly
with the practice to ensure the same situation does not occur again.

In your regulation 28 report you have also highlighted matters of concern for NHS
England which | will address in turn.

1. There would appear to be on-going confusion about who is responsible for
ensuring that those children who are not (for whatever reason), vaccinated at
school, should be vaccinated before attending university. The evidence indicated
that 70% to 80% of children receive the vaccination at school. This would leave
20% to 30% of children unvaccinated. The evidence indicated that GPs should
primarily provide the safety net for unvaccinated children.

The service specifications for Men ACWY and Child Health Information services make
clear the responsibility for delivery of each aspect of the vaccination programme through
school based and GP practice services.

The Men ACWY vaccine was offered routinely to adolescents in school years 9 or 10
from 2015, this replaced the existing Men C vaccine which was routinely administered to
adolescents. In addition, there were a number of phased catch up programmes
throughout 2015 and 2016 which were designed to ensure those up to the age of 18
were caught up and offered the vaccine in school. Those older adolescents who were
not in school, such as those aged 18 years and over, and those attending university for
the first time were eligible for immunisation as part of the GP enhanced service.

The programme was introduced rapidly as part of an outbreak control measure. It was
designed to reduce carriage of the meningococcus bacteria in adolescents and to be
given before the age at which the highest rates of carriage were observed. If enough

High quality care for all, now and for future generations

people in the adolescent community are vaccinated, it's harder for a disease to pass
between people who have not been vaccinated. This is called herd immunity. In order
to achieve herd immunity for the Men ACWY programme Public Health England have
advised that a 70% uptake rate is sufficient; nationally the coverage for children in Year
9 was 82% for the school based programme.

School based providers (eg community trusts, social enterprise, community partnership
etc) are commissioned to offer the vaccine in every school including private and faith
schools which includes the initial offer and opportunities for those that may have missed
this being vaccinated at another time. A key principal of the Men ACWY and all public
health programmes is to offer the intervention to 100% of the eligible population; the
uptake of the vaccination remains the choice of the individual or families. The 20-30% of
children/ young adults not vaccinated in schools therefore fall into two groups:

e offered and declined,
e not offered for a variety of reasons, eg a programme error or incident as in this
case, not attending school, home schooled, etc

GP practices continue to be commissioned as part of a service to opportunistically offer
the vaccine to anyone up to the age of 25. This includes those who may have missed
the opportunity to be immunised as part of the schools based programme:

e those attending university for the first time
e those aged 10 to 25 years who have not previously received a dose of
Meningococcal C containing vaccine.

All GP practices have the responsibility to ensure administrative processes are in place
for service delivery. The process by which a GP practice offers the vaccine to all eligible
children, involves working with the Child Health Information Services (CHIS). | CHIS
have a role to transfer information about public health interventions, transferring this to
and from school based services and GP practice, for those providers to act on and
deliver their services to patients. CHIS services and the ‘failsafe’ they provide are being
improved as part of the NHS strategy for IT, improving the paperless flow of information
across organisations by 2021.

2. The provision of the vaccination against Men ACWY appears to fall under an
enhanced service for GPs. As this is an optional addition to the GMS contract, it
is unclear whether all GP surgeries have a responsibility to capture unvaccinated
children.

You are correct that the provision of the Men ACWY vaccine for those who no longer fall
within the schools based programme is the responsibility of the GP under an enhanced
service. Whilst the enhanced service is optional, GPs have the responsibility of providing
the Men ACWY vaccine for their registered eligible population and must inform NHS
England commissioners as soon as possible if they are not taking up the enhanced
service. NHS England will then ensure that those eligible patients are offered the service
by an alternative primary care provider. Those eligible for immunisation remain eligible
whether or not the practice accepts the service.

3. It does not appear that there is any form of audit to ensure that GP practices
have in place systems to identify those children who are not captured by the
school programme and to put in place measures to protect children, particularly
before commencing university.

High quality care for all, now and for future generations

The Child Health Information Service (CHIS) service is the key organisation locally that
records whether or not a child/ young person has received a vaccine or other public
health interventions, and acts to support the process of capturing information, including
transferring information it receives from school based services to a GP practice, who
then have the responsibility to act on the information received. Each region has an
established system in place to ensure that GP providers are made aware of vaccinations
administered by school aged vaccination providers, with regular reports on the
processed within CHIS coming to a national NHS England oversight group on a quarterly
basis.

NHS England is working to ensure that all those eligible for vaccinations should be
offered the vaccine either in school or by a GP practice. Those who may have missed
the opportunity to be vaccinated, remain eligible until they are 25 years of age.

Although the case of Lauren, is an unfortunate and avoidable death, Public Health
England have advised that there has been a decline in Meningococcal group W cases
overall in England during 2017/18, and this decline is expected to continue to reduce
across all ages including in unvaccinated adolescents and children.

Thank you for bringing your concerns to the attention of NHS England. | hope our
response provides you with reassurance that NHS England are taking proactive steps to
address your concerns.

Yours sincerely,

Professor Stephen Powis
National Medical Director
NHS England

High quality care for all, now and for future generations