Amy Allan

Medical Director’s Office 
medicaldirectorpa@gosh.nhs.uk 
Tel: 020 7405 9200 x 5257  

27/11/2019 

Wednesday, 27 November 2019 

Private & Confidential 

Mr Edwin Buckett 
Assistant Coroner  
Inner North London 
St Pancras Coroner’s Court 

Dear Sir 

Following  receipt  of  your  regulation  28  Prevention  of  Future  Death  Report,  Great  Ormond  Street 
Hospital NHS Foundation Trust (the Trust)  convened a working group of senior clinical staff to identify 
and  implement  the  necessary  actions  to  ensure  that  patients  like  Amy  are  cared  for  in  the  safest 
possible way in future.   

The actions of the Trust are primarily focussed on improving the pathway that Amy experienced at 
GOSH, specifically the spinal surgery pathway with intensive care and ECMO support.  The Trust has 
also  evaluated  how  the  lessons  learned  from  Amy’s  care  are  shared  throughout  the  hospital 
particularly  in  terms  of  improvements  to  the  surgical  pathways  for  other  complex  and  high  risk 
patients.  The Trust recognises that these actions will not change what happened to Amy, but it  hopes 
that these actions will give  her family some comfort and reassurance that the Trust has learnt from 
Amy’s case and continues to do so to ensure that that all patients at the Trust receive the highest 
standard of care.  

These actions which the Trust has taken, and those actions which are currently in progress have been 
summarised below in response to the specific concerns which have been raised.  

(a) It appears that there is a lack of awareness and sharing of information between departments at 
Great Ormond Street Hospital. In particular, the PICU had not been given any advance warning of 
Amy's complex medical background and needs before she was admitted there post operation. As 
PICU staff were not invited to the MDT meetings prior to the operation, they were not aware of the 
'critical time' which lay ahead for her 

The Trust recognises that it is crucial to have processes in place to ensure that all relevant members 
of the multi-disciplinary team (MDT) are part of the decision making processes for complex patients.  
There  are  many  different  MDT  meetings  which  take  place  in  the  Trust  to  enable  this  to  happen, 
including  a  spinal  MDT  meeting.    This  monthly  spinal  MDT  meeting  is  designed  to  ensure  that  all 
elective  spinal  admissions  are  managed  safely  and  that  information  is  shared  accordingly  with  all 
relevant teams.  It was clear from Amy’s case that the spinal MDT meetings had not achieved this for 
her.  The spinal MDT meetings took place without the involvement of all necessary participants, and 
the outcomes of that MDT were not effectively disseminated to all the necessary personnel following 
the meeting.  

1 

 
 
 
 
 
 
 
 
 
 
 The PICU Consultant is an important member of the spinal MDT meeting as many of the spinal patients 
are initially cared for on PICU post operatively.  When Amy’s case was discussed at the spinal MDT 
meetings, the PICU consultant was not present. Although routinely invited to the monthly spinal MDT 
meeting, and were specifically invited to both of the spinal MDTs at which Amy was discussed, the 
PICU consultant was unable to attend. The Terms of Reference (TOR) for the MDT have now been 
amended to mandate the need for the attendance of the identified PICU consultant who acts as liaison 
with the Spinal Team. The TOR also now reflects the responsibility of the PICU consultant to arrange 
appropriate PICU consultant level cover for the spinal MDT meeting in the event that they are unable 
to attend. The same requirement has been applied to all of the additional specialties who are required 
to attend the spinal MDT meeting. The TOR also specifies that it is the responsibility of the MDT Chair 
to  ensure  that  all  relevant  specialties  are  present  for  the  discussion  of  each  case.  If  there  is  no 
representative present then the patient will not be discussed.  If there is a pressing clinical need then 
a further meeting involving all required clinicians before the next monthly spinal MDT meeting will be 
convened by the Chair of the spinal MDT.  A copy of the TOR is enclosed with this response.  

The minutes of the spinal MDT meetings which discussed Amy’s care were not circulated to the PICU 
team.    The  attendance  of  the  relevant  individual  (in  this  case,    the  PICU  Consultant)  at  the  MDT 
meeting  is  best  practice  to  facilitate  appropriate  conversation,  and  the  circulation  of  the  minutes 
provides additional opportunities for other members of the broader clinical teams to understand the 
needs of patients who may be admitted under their care.   At the time Amy’s care was discussed at 
the spinal MDT meetings, the notes of the meeting were typed up and generally circulated via email. 
However, the notes of the MDT meetings at which Amy was discussed were not circulated to the PICU 
Consultants.  

In  April  2019  the  Trust  launched  a  new  electronic  patient  record  system  (Epic)  that  replaces  the 
previous paper records and combines numerous existing electronic systems.  Epic now enables the 
notes of MDT meetings to be recorded directly within the individual patient’s records. It is therefore 
much  easier  for  all  teams  involved  in  caring  for  a  patient  to  access  the  outcome  of  the  MDT 
discussions.  Epic also includes a messaging system (similar to email) within the patient’s records to 
support clinicians discussing the patient’s care and to ensure that those messages are directly linked 
to the patient’s records.  This provides a much better awareness and sharing of information between 
departments.  

In addition to the safety improvements which Epic brings, the Trust has made a number of changes to 
ensure that the outcome of the spinal MDT meeting are effectively communicated.  This includes: 

  Flagging high risk patients on the electronic PICU booking form; 
  Requiring the PICU consultant who attended the spinal MDT to brief the PICU team on any elective 

spinal admissions to PICU as part of their weekly consultant meeting; 

  Requiring the spinal CNS to send an email reminder to the PICU consultants regarding high risk 
spinal patients a week before admission and on the day of admission to ensure that the consultant 
who is in charge of the unit on the day of admission is aware of the known risks; 

  Requiring the PICU consultant in charge of the unit on the day of admission to discuss the planned 
admissions for the day after the morning ward round to update themselves and the team about 
any known risks. 

The Trust believes that these requirements ensure the PICU consultant in charge, on any given day, is 
appropriately  aware  of  high  risk  patients  admitted  to  the  intensive  care  unit.  Further  work  is  also 
underway to develop enhanced electronic Patient Status Boards within Epic. The boards will include 
2 

 
 
 an overview of all patients on the unit (or those due to be admitted imminently). It will provide key 
clinical information, including high risk status, on one screen.  This work is being supported by the 
Electronic Patient Record team and is already underway. It is anticipated that these boards will be in 
use from January 2020.  

In addition to strengthening the pathways for spinal patients with complex co-morbidities, the Trust 
has also reviewed how it can apply the learning from Amy’s case to other surgical pathways.  As a 
result two significant projects are now underway: 

  Expanding  the  provision  of  Anaesthetic  Pre-Operative  Assessment  (APOA)  to  all  GOSH  patients 

undergoing an elective intervention under general anaesthetic 
o  This service triages patients according to their level of risk into an appropriate pre-operative 
appointment with the anaesthetic team (i.e. telephone appointment, face to face with nurse or 
face  to  face  with  anaesthetist).  Risk  is  determined  based  on    a  number  of  factors  including; 
comorbidity, complexity of intervention and assessment of risk at triage; 

o  This triage will identify those particularly high risk patients for whom a Complex Patient MDT 
meeting should be organised. This would include the need for cardiac and PICU Consultant, and 
other  relevant  specialties,  to  attend.  This  Complex  Patient  MDT  would  determine  the  peri-
operative plan and post-operative location for the patient.  

o  The APOA service is not currently used by all specialities within the Trust, as much of the pre-
operative assessment process is managed at specialty level by the Clinical Nurse Specialist (CNS) 
who supports the surgical teams; 

o  Referrals  will  be  made  to  the  Joint  Cardiac  Conference  (JCC)  as  required  by  the  cardiac 
representative at this Complex Patient MDT.  In cases where ECMO is identified as a possibility, 
there will be cardiac intensive care team involvement in the consent process. 

o  The  expansion  of  this  service  will  be  phased  to  allow  necessary  recruitment  into  the  APOA 
service. The first phase of expansion is planned to take place in January 2020. The Trust expects 
to  be  in  a  position  to  mandate  the  requirement  for  all  patients  undergoing  an  intervention 
under  GA  to  be  triaged  by  APOA  within  9-12  months,  namely  by  November  2020.      The 
implementation progress will be tracked through the Patient Safety and Outcomes Committee.  

  Improving the governance of MDT meetings 

o  Amy’s  journey  demonstrated  how  important  it  is  that  the  Trust  has  good  governance 
arrangements  in  place  for  all  MDT  meetings  to  ensure  that  all  relevant    clinicians  are  in 
attendance; that meetings  are  appropriately  documented  and  the  information  disseminated 
effectively to the right staff; and that all actions arising from MDTs are completed;  

o  A consultant surgeon has been identified by the Medical Director to lead a project to guide best 

practice in conducting MDTs across the Trust. This began in October 2019; 

o  Trust wide requirements for MDT attendance and documentation have now been agreed. The 
requirements  will  shared  with  the  Operational  Board  on  the  11th  December  2019  for 
dissemination to operational clinical teams to action.  

o  A baseline audit of current MDT performance began in November 2019 and the results will be 
reviewed at our Patient Safety and Outcomes Committee to support Trust -wide improvement. 
The results of this audit are due to be discussed at the December 2019 meeting.  

o  An  annual  audit  has  been agreed to  ensure  that  the Trust  has  assurance  that  the  MDTs  are 
working effectively to provide the safest care to our patients. The frequency of the audits may 
increase depending on the results of the audit 

3 

 
 
 
 The learning from Amy’s case, and the Trust-wide changes we have made as a result will be discussed 
at the Surgical Forum on the 13th December 2019.  This forum brings together all of the Consultant 
Surgeons at the Trust to facilitate discussion and cross-specialty learning. The Trust thinks that sharing 
Amy’s story in this way will ensure that the surgical teams understand the importance of the changes 
to our systems and processes.  

(b) There was no clear plan or instruction for the management of Amy post operation in relation to 
extubation and ECMO support on the PICU 

The Spinal MDT TOR have been amended to include the specific responsibilities for clinicians attending 
the meeting in regards to ECMO. This is reiterated in the PICU guidance for managing spinal patients. 
A copy of this guidance is enclosed [Spinal Surgery Pathway PICU FINAL].  

The new agreed process is as follows: 

  If a patient discussed at the spinal MDT is identified as potentially requiring ECMO support post- 
operatively, their case will be referred to the Joint Cardiac Conference (JCC) by the Cardiologist 
present at the Spinal MDT (or by another appropriately briefed cardiology consultant);  

  The  JCC  will  review  the  case  and  determine  whether  ECMO  support  post-  operatively  is 

appropriate;  

  If  the  JCC  consider  that  pulmonary  hypertension,  or  another  cardiorespiratory  condition,  is  a 
significant issue and ECMO is being considered, then the JCC will identify the safest environment 
for the patient’s post-operative care (Cardiac Intensive Care Unit or Paediatric Intensive Care Unit) 
in light of the patient’s overall condition.  

  The JCC will also confirm who will participate in the joint consent process with spinal surgeon to 
ensure that  the patient and family receive appropriate patient information and counselling during 
the consent process;  

  The cardiologist linked to the spinal MDT will share the outcome of the JCC with the spinal team 
(either via the next spinal MDT or through the Spinal Consultant or the spinal CNS team if the case 
is more clinically urgent). This information will also be recorded as the outcome  of the JCC MDT 
discussion in the patient record on Epic so that the post-operative management plan for ECMO is 
available to all staff caring for the patient; 

  On the day of the operation, the consultant anaesthetist will contact the ECMO team to confirm 

that there is ECMO capacity as well as ICU bed capacity.  

  Following the post-operative evening ward round on PICU/CICU, there will be a formal discussion 
between the PICU Consultant, CICU Consultant and the Perfusionist-on-call regarding the high risk 
patients on both units, so that all relevant team members are briefed on the patient’s condition 
ahead of the night shift. 

The  plans  and  instructions  for  management  of  extubation  are  guided  by  the  patient’s  consultant 
anaesthetist  on  the  basis  of  the  patient’s  response  to  the  general  anaesthetic  on  the  day  of  the 
procedure. This means that the handover between the anaesthetic and PICU team is a crucial safety 
mechanism. The changes which the Trust has made in relation to the anaesthetic-PICU handover are 
outlined in paragraph (c).  

The plans for extubation may evolve over the course of the patient’s post-operative course for several 
different reasons and the PICU Consultant is responsible for making decisions based on the patient’s 

4 

 
 
 
 clinical condition once the patient is on PICU.  The PICU Consultant is also responsible for ensuring 
that  the  plan  is  clearly  articulated,  documented  and  understood  by  the  clinical  team  supporting 
delivery of care in PICU.  We undertake twice yearly documentation audits on PICU in line with the 
NHS  7  day  service  reporting  requirements.  This 
includes  evaluation  of  consultant  review 
documentation at least twice daily. The audit was most recently completed in October 2019 and the 
outcome was presented to the Patient Safety Outcomes Committee in November 2019. The results 
identified  the  need  for  additional  computers  on  the  unit  to  ensure  that  all  documentation  can  be 
completed in a timely way. Additional computers were received on the unit in November 2019.  

(c) The handover between clinicians involved in Amy's operation and those taking over her care in 
the PICU, was poorly executed with vital information either not properly conveyed or recorded or 
simply missed. 

The Electronic Patient Record department is currently supporting the Anaesthetic and ICU teams to 
develop a standardised electronic handover document which mirrors the paper form which has been 
developed for this purpose.  The electronic handover document will ensure that all the relevant fields 
are together in one section so that they can be clearly and easily discussed as part of a structure verbal 
handover, and act as an ongoing plan to support the ICU team.   

The electronic handover is currently being tested by the Electronic Patient Record team to ensure that 
it  provides  a  secure  platform  for  the  anaesthetic  and  intensive  care  teams.  This  is  expected  to  be 
completed  by  February  2020.    This will  be  accompanied  by  an  appropriate  training  programme  to 
standardise  handover  between  the  two  specialties  to  ensure  that  both  the  correct  information 
required is available and the personnel who need to be present to receive it are in attendance. The 
lessons we have learned from Amy’s care will be incorporated in this training.  The Trust expects to 
launch the new electronic handover in February 2020.  In the interim, the anaesthetic and ICU teams 
will continue to use the paper form (which will then be scanned onto the Epic system).  

The  Trust  expects  this  handover  to  take  place  between  the  Anaesthetic  Consultant  and  the  PICU 
Consultant whenever possible. The Clinical Lead for PICU and the Clinical Lead for Anaesthetics have 
reminded all Consultants of this requirement again in November 2019. When it is not possible (e.g. 
PICU Consultant is busy with another patient), handover should be given to the most senior doctor on 
the  unit,  who  will  then  share  that  information,  alongside  the  handover  document,  with  the  PICU 
Consultant. Where further discussions about the patient between the Anaesthetic Consultant and the 
PICU  Consultant  are  required,  these  are  now  recorded  in  Epic.  It  is  the  responsibility  of  the  PICU 
Consultant to record this information.  

(d) There was a delay in commencing ECMO support 

ECMO is an invasive therapy that may sustain life where the natural history of the underlying 
condition is understood or modifiable. The Trust is commissioned to provide ECMO support for post-
operative cardiac patients and respiratory patients in the South East of England. These children are 
generally either: 

(i) 
(ii) 

known to the cardiac team; or 

 referred with circulatory and/ or respiratory failure that is refractory to conventional 

intensive care therapy  

5 

 
 
 
 
 Patients being considered for ECMO commonly have life threatening physiological signs and metabolic 
disturbance consistent with failure to respond to conventional intensive care therapy. Once a patient 
is receiving ECMO, the underlying conditions may improve with supportive measures (eg resting the 
heart after heart surgery or cessation of aggressive ventilation with influenza) or specific treatments 
(e.g. further surgery or antibiotics). With increased complexity, including chronic multi-system or life 
limiting  conditions,  the  balance  of  risk  and  benefit  becomes  less  clear,  and  the  clinical  outcomes 
become uncertain. 

The Trust does not standardly provide rescue extra corporeal life support (ECLS) for all other patients 
who may collapse within the Trust. However, the Trust aims to provide ECLS wherever possible to 
patients who are likely to gain benefit.  The decision to deploy ECLS routinely includes: 

1.  an assessment of response to escalation of medical therapy coupled with; 
2.  discussions with the treating team and family regarding anticipated outcomes, whilst; 
3.  assembling the team and planning for a surgical cannulation procedure. 

There are inherent delays in this approach and there are no local, national or international timescales 
for ECMO cannulation. Whilst the ECMO team always works hard to avoid unnecessary delays, it is 
recognised that it is not always possible to get this judgement right and they err on the side of safety. 
Often transferring a critically ill patient to Great Ormond Street for ECMO or assembling the ECMO 
team does not culminate in cannulation for ECMO because it has been possible to stabilise the patient 
with conventional ICU therapy. In that situation the ECMO team is retained ‘on standby’ in case of 
deterioration. 

When  Amy  was  on  PICU  the  clinical  need  for  ECMO  was  identified  at  approximately  3am  on  5th 
September 2018.  The Cardiac Intensive Care Consultant was contacted by the PICU Consultant and 
they confirmed at approximately 3.30am that the ECMO team was being assembled and this would 
take approximately 45 minutes. The PICU Consultant wanted the ECMO team for support in the event 
of a cardiac arrest during intubation. Amy’s clinical condition deteriorated significantly (with systolic 
blood  pressure  below  60mmHg  accompanied  with  a  drop  in  her  level  of  consciousness)  and  this 
necessitated re-intubation ahead of the ECMO team arrival. The ECMO team were onsite just after 
4am  as  Amy  was  being  intubated.  Amy  tolerated  re-intubation  and  showed  some  initial  signs  of 
improvement with an echocardiogram showing improvement in the function of the right side of her 
heart. While the ECMO circuits were being prepared by the ECMO team, the PICU team tried various 
conventional management strategies (including vasopressin, sodium bicarbonate, magnesium and a 
blood transfusion) to see if ECMO could be avoided.  Initially there were some improvements in Amy’s 
condition,  so  the  decision  to  cannulate  was  delayed.  However,  there  was  no  significant  clinical 
improvement  overall  and  therefore  the  clinical  decision  to  put  Amy  on  ECMO  was  taken  at 
approximately 7.15am and ECMO cannulation began. She was cannulated and started on ECMO at 
8.30am.  

In order to put patients on ECMO, a team of experienced professionals is required. The majority of 
staff groups required as part of the ECMO team are part of other 24/7 rotas. However, we do not have 
a resident on-call perfusion service 24/7, as the need for unanticipated rescue ECLS out of hours is 
rare.  The  Perfusion  team  (specialists  that  routinely manage  patients  on  heart-lung  bypass  circuits) 
have an important role in decisions regarding the mode of ECMO, size of cannula and physical site of 
cannulation in addition to an active involvement during the cannulation process. However, outside 
their  contracted  hours,  the  on-call  perfusionists  may  not  be  on  site unless  a  patient  at  risk  of 
decompensation has been highlighted or an emergency bypass surgery (such as a transplant) is being 

6 

 
 
 undertaken. If the perfusionists are required to stay on site, they are provided with appropriate rest 
facilities.  If there is an emergency involving a patient not known to the ECMO team (including patients 
who may be transferred in from other hospitals), but one for whom it is agreed that ECLS would be in 
their best interests, then the team are called in from home. This is similar to arrangements for out of 
hours theatre cases.  

The new agreed process for the identification of patients like Amy (articulated above) ensures that: 

  there is a more robust pathway for involving the members of the cardiac and ECMO team in pre-

operative preparation via the JCC meeting; 

  that patients and families have a better understanding of what ECMO entails and how the process 

will work; 

  that the PICU consultant on the day of admission has a clear understanding of any patient who has 

been identified as potentially requiring ECMO; 

  there is a pre-operative check by the anaesthetist to confirm ECLS capacity on the morning of the 

procedure; and 

  it ensures that the perfusion team are able to identify when they need to stay on site as part of 

their on-call.  

(e) No single properly informed clinician appeared to be coordinating Amy's post-operative care in 
such a complex and high risk case. 

The nature of caring for complex surgical patients means that there will be several clinicians involved 
in  their  care.  This  also  means  there  will  be  different  individual  clinicians  responsible  for  and 
coordinating care at different points in their surgical pathway according to their clinical expertise.  In 
Amy’s  case  the  individuals  were:  the  Consultant  Spinal  Surgeon,  Consultant  Anaesthetist  and  the 
Consultant  Intensivist.    Effective  communication  and  handover  between  the  teams  are  crucial  in 
providing safe care. Below is a table of showing the surgical pathway that details the responsibilities 
of a particular clinical speciality at each stage of the pathway: 

Surgical Pathway Stage 
Pre-operative assessment  

Person responsible for care 
Spinal Consultant 

- 

Including  arranging  quorate  MDT 
decision making 

Bed booking 

Spinal Consultant 

- 

- 

Including flagging of high risk patients on 
the booking forms  
to  PICU 
Including  email 
Consultants  one  week  before  admission 
and on the day of admission 

reminder 

Pre-operative admission management 
Intra-operative management 

Handover to PICU 
Immediate post-operative care 
Ongoing post-operative care following discharge 
from PICU 

-  Undertaken  by  the  Spinal  CNS  on  their 

behalf. 

Spinal Consultant 
Jointly  managed  by  Spinal  Consultant  and 
Anaesthetic Consultant 
Anaesthetic Consultant to PICU Consultant 
PICU Consultant 
Spinal Consultant 

7 

 
 
 
 
 To ensure that all staff members involved in the care are clear about the pathway, and their roles and 
responsibilities within that pathway, the  PICU Consultant Team have now also developed a guideline 
on the spinal surgery pathway for complex cardiac patients admitted to PICU.  A copy of this guideline 
is enclosed [Spinal Surgery Pathway PICU FINAL].  

The PICU Consultant had responsibility for Amy’s post-operative care following transfer to the unit.  
The  Trust  operates  a  closed  intensive  care  model.  A  closed  intensive  care  model  is  when  the 
responsibility  for  decision  making  is  taken  by  the  intensive  care  unit  consultants.  This  is  done  in 
collaboration with other specialists, including the surgeons and anaesthetists, but the intensivists are 
the decision makers and they direct care for the patients whilst they remain on ICU. The ICU is staffed 
with intensivists directly responsible for care. 

An open unit model is when each specialist (e.g. a surgical consultant) is responsible for directing the 
care of their patients whilst on ICU; these specialists are not intensivists. 

The PICU at Great Ormond Street Hospital is a closed unit so responsibility for care of patients whilst 
they are on the ICU is that of the intensive care consultants. 

Research has demonstrated the evidence of better outcomes for patients on a closed versus an open 
ICU. 

  Provonost, JAMA 2002: High intensity versus low intensity ICU physician staffing is associated with 

reduced hospital and ICU mortality and ICU length of stay. 

  Treggiani, AJRCCM 2007: In a cohort study of patients with acute lung injury, admission to a closed 
model  of  intensive  care  unit  was  associated  with  reduced  mortality  independently  of  patients’ 
characteristics.  These  findings  support  recommendations  to  implement  closed  model  intensive 
care units. 

  El-Kersh,  Am  J  Infect  Control  2016:  Infectious  complications  in  the  intensive  care  unit (ICU)  are 
associated  with  higher  morbidity,  mortality, and  increased  health care  use.  Reported  results  of 
implementing  2  different  models  (open  vs  closed)  on  infectious  complications  in  the  ICU.  The 
closed  ICU  model  was  associated  with  52%  reduction  in  ventilator-associated  pneumonia  rate 
(P = .038) and 25% reduction in central line-associated bloodstream infection rate (P = .631). We 
speculate that a closed ICU model allows clinical leadership centralization that further facilitates 
standardized care delivery that translates into fewer infectious complications. 

  Wilcox  E,  CCM  2013:  Meta-analysis  of  52  studies  demonstrating  that  high  intensity  intensivist 

staffing reduces ICU and hospital mortality in critically ill patients. 

  Core Standards for Intensive Care Units 2013, Faculty of Intensive Care Medicine, UK   

The closed unit structure clearly defines which single clinician is responsible for care.  In Amy’s case, 
our  systems  and  processes  failed  to  provide  that  PICU  Consultant with  all of the  information  they 
needed, and at the time they needed it, to deliver the care that Amy required. The changes that the 
Trust has outlined in the preceding paragraphs (MDT meeting management; MDT documentation on 
Epic; PICU high risk patient booking forms; PICU consultant meetings; weekly and on admission email 
reminders  to  PICU  consultants;  PICU  patient  summary  review  on  the  morning  of  admission;  and  
anaesthetic consultant to PICU consultant handover) set out the way in which the PICU Consultant 
now receives that information, as well as the work the Trust  undertaking to improve and refine this 
further.  

8 

 
 
 
 Monitoring of ongoing actions 

The Trust, and all of those staff involved in Amy’s care, are very sorry for what has happened. The 
Trust recognises that there were failings in our systems and processes to protect Amy, and the Trust 
is committed to ensuring that there is lasting organisational change as a result. These changes will 
impact  the  spinal  surgical  pathway,  and  will  also  impact  the  pathways  of  all  complex  patients 
undergoing  general  anaesthetic  at  the  hospital.  There  is  a  diagram  enclosed  with  this  response 
[Pathway Comparison] which aims to show how the pathway for high risk spinal patients like Amy is 
different now, as a result of the lessons we have learned from her care. 

The actions outlined in this document will be scrutinised through our internal governance processes 
including: 

  Monthly  detailed  review  of  ongoing  actions  through  Closing  the  Loop  meeting  (Chair:  Medical 

Director); 

  Update on overall progress, and results of associated audits will be completed by the Patient Safety 

and Outcomes Committee (Chair: Medical Director); 

  Assurance on the completion and impact of the actions taken will be provided quarterly to the 

Quality Safety and Experience Committee (Chair:  Non-Executive Director); 

  External scrutiny will be undertaken by NHS England and the Care Quality Commission.  

NHS England will be updated on progress with the action plan through monthly Clinical Quality Review 
Group  meetings.    The  Care  Quality  Commission  will  be  updated  regularly  as  part  of  relationship 
management meetings.  

The Trust would also be willing to provide Amy’s family with regular updates (either directly or through 
their solicitors) on the progress that has been made, if they would find that beneficial.  

Yours Sincerely 

Dr Sanjiv Sharma 

Dr Sanjiv Sharma  
Executive Medical Director 
Consultant Paediatric Intensive Care 
Executive Offices 
Level 2 Barclay House  
Great Ormond Street Hospital NHS Foundation Trust 
London WC1N 3BH 

9 

 
 
 
 
 
  
 
 Terms of Reference 
Spinal Service Multidisciplinary Team Meeting 

1 Purpose  

The Spinal MDT meeting (SMDT) is responsible for co-ordinating a cross speciality approach to agreeing each 
complex patient’s continuation to a Spinal Surgical intervention.  Its scope includes all patients on the waiting 
list for spinal surgery identified as complex and requiring review and individualised plan of care.  

From September 2019 the SMDT will include a spinal M+M and present results of audits undertaken by the 
spinal team. This meeting will be held from 08:00 – 12:00.  

2. Objectives 

The objective of SMDT is;  

 
 
 

 

 

 
 
 

To ensure multi-speciality agreement on patients who should proceed to surgical intervention. 
To ensure complex patient have a full systems review prior to surgical intervention. 
To ensure patients identified as complex have an individualised plan of care for the duration of their 
patient journey up to and including a safe discharge.  
To ensure all departments involved in the patient’s journey have access to the individualised plan of 
care.  
To ensure that patients receive all levels of inpatient care in designated areas which have the 
resources required to provide the level of care needed. 
To continue to reduce length of stay within the division. 
To improve the safety and standards of patient care within the division.  
To improve the patient and family experience within the division. 

3 Core Membership and Responsibilities  

The SMDT core membership is multi-disciplinary with representation from professionals across the care 
pathway.  All core members are required to regularly attend the SMDT meetings and activity engage and 
support the delivery of the SMDTs purpose and objectives. 

For a quorum, the following core members must attend: 

 1. Two consultant surgeons (where one consultant is on annual leave, they must provide comments prior to 
the meeting. Comments must be received by the Clinical Nurse Specialist (CNS) Team/Advanced Nurse 
Practitioner (ANP) by 2pm on the Friday preceding the meeting) 

2. Cardiology Consultant 

3. Respiratory Consultant 

 4. Anaesthetic Consultant 

1 

 
 
 
 
 
 
 
 
 
 
 
 
 5. General Paediatrician (Consultant) 

6. Paediatric Intensive Care Consultant 

7. Spinal Clinical Nurse Specialist (CNS)  

8. Spinal Fellow (if not available a second CNS to present the x-rays and MRI’s) 

9. Physiotherapist 

10. Occupational Therapist 

11. Administrator (taking list of attendees) 

Others: 

(a)  Where there are combined neurosurgery spine cases to be discussed then Dominic Thompson, 

Consultant Neurosurgeon, to attend.  

(b)  Where there are neuromuscular cases to be discussed then Adnan Manzur, Neuromuscular 

Consultant, to attend. 

(c)  Where there are neuro-disability cases Catherine DeVile +/- Belinda Crowe will be invited 

(d)  Where additional radiological (including neuro radiological) experience is required then an 

appropriate consultant radiologist will be invited.  

(e)  In the event of complex cardiac patients, including patients needing ECMO backup, the Consultant 

Cardiologist must be in attendance at the MDT  
For patients with known pulmonary hypertension, a specialist pulmonary hypertension consultant 
must be in attendance for the discussion of the patient. 
The cardiologist/ pulmonary hypertension consultant will then decide if it necessary for the patient to 
be discussed further at the cardiac joint case conference (JCC) and will make this referral directly.   
All patients identified as potential candidates for ECMO backup must be discussed at the cardiac JCC. 
The outcome of the JCC discussion must be fed back at the subsequent Spinal MDT meeting by the 
Consultant Cardiologist. In the event of clinical urgency, the Consultant cardiologist should feedback 
to the Spinal CNS team and arrangements will be made for an ad hoc MDT.   

(f)  Other clinicians may be invited to the meeting on an adhoc basis depending on the clinical needs of 

the patient due to be discussed.  

The group membership is agreed and detailed below: 

Spinal MDT Attendance List 

Name 

Title 

Attended 

Arrival Time 

Adnan Manzur 
Aimi McEwan  
Caroline Haynes  
Claire Cook  

Neuromuscular Consultant  
Physiotherapist 
Occupational Therapist 
Spinal Theatre Sister  

2 

 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
  
  
 Dominic Thompson  
Edel Broomfield 
Elaine Chan 
Evangelia Papathanasiou 
Francois Abel 
Grant Stuart 
Hiromi Kawai  
Imke Meyer-Parsonson  
Ioannis Ioannou 
Jonathan Smith  
Joy Dawes  
Sophie Tamiam 
Liz Jackson  
Loren Wailes  
Lucy Howlett  
Marina George  
Mark Harris 
Pascale Du Pre 
Pratheeban Nambyiah 
Ramesh Nadarajah 
Sarah Harmar 
Sian Pincott 
Stacey Lambourne  
Saadiyah Dana  
Stewart Tucker 
Sophie Tamiam 
Suzanne Close  
Tom Ember 

4 Operational Processes  

Consultant Neurosurgeon  
Advanced Nurse Practitioner 
Respiratory Consultant 
Cardiology Consultant 
Respiratory Consultant 
Consultant Anaesthetist   
Administrator  
General Paediatrician  
Consultant Anaesthetist   
Consultant Anaesthetist   
Consultant Anaesthetist   
Medical Secretary  
Consultant Anaesthetist   
Clinical Nurse Specialist  
Clinical Nurse Specialist 
Consultant Anaesthetist   
Consultant Spinal Surgeon 
PICU consultant 
Consultant Anaesthetist   
Consultant Spinal Surgeon 
Physiotherapist 
General Paediatrician  
Clinical Nurse Specialist 
Medical Secretary 
Consultant Spinal Surgeon  
Spinal secretary 
Physiotherapist 
Consultant Spinal Surgeon 

From September 2019: One meeting per month, on a Tuesday for 4 hours (i.e. one PA DCC time per month or 
0.25 per week).  
MDT Schedule:  

Theatre 14 
 Start time 

Theatre 15 
Start times 

26/11/2019 
17/12/2019 
21/01/2020 
18/02/2020 
17/03/2020 
14/04/2020 
12/05/2020 
19/06/2020 
07/07/2020 
04/08/2020 
01/09/2020 
29/09/2020 

12:00 
08:15 
08.15 
08.15 
08.15 
08.15 
08.15 
08.15 
08.15 
08.15 
08.15 
08.15 

08:15 
12:00 
11.00 
11.00 
11.00 
11.00 
11.00 
11.00 
11.00 
11.00 
11.00 
11.00 

3 

 
 
  
  
  
  
  
  
 
 
  
  
  
  
  
  
  
  
 
 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
 
 
  
  
  
  
 
 
 
 27/10/2020 
24/11/2020 
22/12/2020 

08.15 
08.15 
08.15 

11.00 
11.00 
11.00 

5 Chair 
The meeting is alternately chaired by Mark Harris, Spinal Surgeon and Imke Meyer Parsons, Consultant 
Paediatrician. The name of the chair will be confirmed in the minutes of the MDT meeting.  

The chair is responsible for ensuring that the TOR are followed.  This includes ensuring that the meeting is 
appropriately quorate for the discussion of each patient.  

If the named consultants (or appropriate deputies) required to discuss a case are absent, the patient case 
discussion will be deferred until the next meeting.  In the event of clinical urgency, then an ad hoc MDT 
meeting with the relevant professionals must be arranged.  

If feedback and advice is sought from another MDT or professional before confirming a spinal MDT decision, 
the chair must ensure that the case is re-listed at the next spinal MDT or make arrangements for and ad hoc 
MDT meeting with the relevant professionals must be arranged. 

6 Administration  

6.1 Meeting Notifications 
Group core members will be notified of meeting dates and changes to meeting data in advance with a 
minimum of three weeks’ notice.  

6.2 Documentation 
Minutes should either be typed directly into Epic at the meeting (or using voice recognition software) by the 
Advanced Nurse Practitioner. The notes taken at the meeting will be reviewed with the meeting chair for sign 
off. The minutes must be signed off by the chair within 2 working days. 

6.3 Attendance 
All core members of the MDT are required to attend the meeting. 

In exceptional cases where core member attendance is not possible, a suitable deputy, who is briefed and at 
an appropriate level to make decisions in a members absence, should be arranged by the named specialty 
consultant. Apologies, together with the deputy’s details must be sent to the SMDT administration support by 
the named specialty consultant.  

7 Monitoring 

The service manager for the spinal service, together with the core SMDT members shall review its 
effectiveness through audit on an annual basis.  This will involve monitoring and reporting on: 

 
Frequency of meetings 
  Attendance at meetings; and 
 

Compliance with the requirements outlined in the terms of reference 

The spinal MDT terms of reference will be reviewed by the service manager, in conjunction with members of 
the MDT, on an annual basis or more frequently if needed.  

Changes in the TOR must be approved at the MDT meeting.  

Next review due: November 2020  

4 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Spinal Surgery Pathway for Patients Admitted to PICU   

Surgical pathway applicable for combined, anterior and posterior approach spinal fusion, 
and insertion of growth rods. (Full integrated care pathways available on EPIC) 

Appendix 1- spinal MDT decision flow chart for complex cardiac patients  

Appendix 2- pulmonary hypertension pathway  

Pre-operative assessment   

Each spinal patient is discussed in the spinal MDT and assessed for risk by; respiratory, cardiology, 
anaesthetic and spinal surgery. Other specialties attend as indicated e.g. pulmonary hypertension 
and neuromuscular team. All patients with complex cardiac conditions, significant pulmonary 
hypertension or cardiac failure discussed in the JCC and discussion fed back to Spinal MDT (see 
appendix 1). Indication for surgery and appropriateness of surgery given risk is discussed. PICU 
representative must be present at each meeting, provisionally accepts if appropriate and flags high 
risk patients to spinal CNS.  Any specific post-operative recommendations are documented in MDT 
notes.   

Certain high-risk patients discussed at PICU consultant meeting at PICU links discretion for 
disseminating information and plan refinement (will include but not exclusive to patients with 
complex cardiac co-morbidities). Disagreement to be fed back to spinal MDT by PICU link.  

PICU bed to be requested by spinal CNS on EPIC stating; high risk spinal patient, surgery planned and 
indication for PICU.  

PICU link and PICU clinical lead informed of scheduled admission of high-risk patients by spinal CNS 
by e-mail the week before surgery. PICU link updates admitting Consultant team (1st, 2nd and 
support PICU Consultant on call) with high risk status and any specific post-op recommendations. 
PICU link to include relevant specialties as required. 

Admission  

Admission as requested by spinal team. Patients with pulmonary hypertension being stabilised on IV 
sildenafil pre-op admitted to PICU for cardiology and pulmonary hypertension team review (see 
appendix 2)  

High risk patients to be prioritised on theatre list aiming to return from theatres before 1900.  

Intra-operative management 

Intra-op management as per spinal anaesthetic team.  Patients with pulmonary hypertension to 
continue IV sildenafil if already established on it and inhaled nitric oxide to be available. 

PICU November 2019 

 
 
 
 Spinal Surgery Pathway for Patients Admitted to PICU   

Post-operative management- High risk patients  

Transferred to PICU ventilated with IABP monitoring. 

Anaesthetic Consultant to PICU Consultant handover on PICU. Handover to include high risk status, 
post-op recommendations and discussion on timing of extubation. PICU Consultant to co-ordinate 
post-op management. 

Patients with Pulmonary Hypertension (see appendix 2): start CVP monitoring, continue IV 
sildenafil with inhaled nitric oxide available. Optimise analgesia, avoid acidosis, avoid hypoxia 
(physiotherapy and optimising lung volumes), and avoid hypotension (whilst avoiding fluid 
overload). Oral sildenafil to be reintroduced once tolerating feeds. 

Cardiology and pulmonary hypertension team assessment pre-extubation and pre-discharge to 
HDU as indicated.  Extubation once stable after first night post op during day shift. 

Patients with known pulmonary hypertension with signs of pulmonary hypertensive crisis or low 
cardiac output at any stage: Medical management optimisation as above, achieve alkalosis, high 
FiO2, inhaled nitric oxide, inotropes to achieve systemic blood pressures above pulmonary pressures 
and consider milrinone if systemic pressure allows. Urgent cardiology review and ECLS/CICU 
referral if evidence of ongoing low cardiac output or hypoxia. 

Patients with difficult airway or high risk of tracheostomy also to be extubated in working hours 
with appropriate teams informed as indicated by intraoperative assessment or pre-op plan. If known 
to be difficult to bag mask ventilate theatre availability for extubation should be confirmed pre-op. 
Handover to ward teams and involved specialties with CSP review prior to discharge as per usual 
care. 

Spinal surgery- low risk and usual post-operative care  

PICU post-operative care-day of admission  

Sky bed to be sent when patient ready for collection 

Anaesthetic team hand over including any specific post-operative recommendations  

Post-op plan and timing of extubation if ventilated discussed with PICU Consultant   

Commence ABP monitoring as indicated.  Routine post-operative observations ¼ hourly 

Chest X-Ray  

Keep NBM, commence IV fluids, and place NG tube on free drainage  

Administer analgesia IV / PR as required. Monitor pain scores hourly 

Monitor and record neurovascular observations ½ hourly for the first 4 hours then hourly 

Monitor wound site for oozing – apply pressure dressing if required 

Monitor urine output- medical review if urine output below 1ml/kg/hour 

PICU November 2019 

 Spinal Surgery Pathway for Patients Admitted to PICU   

Administer IV antibiotics as per microbiology policy and ensure prescribed at the correct time post 
dose in theatres. 

Post combined or anterior spinal fusion; monitor and record chest drain loses hourly  

Nurse supine for 12 hours then log roll 2 hourly, attending to pressure area care at least 2hourly 

Obtain post-operative blood samples for FBC, U+E and clotting 

Low risk patients highlighted for early discharge discussed at evening bed meeting and night CSP 
to review before handing over (including patient’s extubated at 0600). Day team to review if still 
ventilated  

Post-procedure day 1 – Transfer from PICU to post-operative ward 

Ensure arterial line removed after doing post op bloods if no longer required and transfer to Sky bed 
if not already done.  

Catheter to remain in situ 

Central line to remain in situ 

Pain team review and PCA/NCA converted to ward settings prior to discharge 

Review on post-operative ward round by spinal team 

Handover from intensive care team to spinal team  

CSP review prior to discharge if not already done 

Post-procedure day 1 usual ward care if still on PICU is as follows; 

Continue to monitor neurovascular observations hourly 

NBM, continue IV fluids, NG tube on free drainage  

Check for bowel sounds – consider commencing oral fluids if present and spigot NG tube 

If IV fluids continue – obtain blood sample for U&E 

Convert NCA to PCA after pain team review, monitor pain scores hourly 

Monitor wound site for oozing and administer IV antibiotics as per policy  

Monitor urine output-medical review if urine output below 1ml/kg/hour 

Monitor and record chest drain loses 

Assist to turn 2hourly and attend to pressure area care at least 2hourly 

Review by physiotherapist and OT daily as indicated; Sit or mobilise as directed by operation note 

Contact orthotics were appropriate to arrange timing of cast for brace if required 

PICU November 2019 

 
 
 Spinal Surgery Pathway for Patients Admitted to PICU   

Post-procedure day 2, Instructions as per day 1 except; 

Listen for bowel sounds and commence oral fluid if present 

If IV fluids continued obtain blood sample for U&E 

Spigot NG tube and remove once tolerating oral fluid and diet 

Pain team review and convert PCA to oral medication when tolerating enteral diet 

Remove catheter if appropriate once off opiates– ensure urine passed within 12 hours 

Attend to pressure area care as a minimum 2 hourly 

If no brace required sit to angle as directed by operation note 

Post-procedure day 3, Instructions as per day 2 except; 

Monitor and record chest drain loses – remove when less than 150ml in 24 hours and chest x-ray 
review. Obtain chest x-ray pre and post removal 

Commence laxatives if bowels not open 

Assist with turns and attend to pressure area care 2 to 4 hourly 

Discharge process as above 

PICU November 2019 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Spinal Surgery Pathway for Patients Admitted to PICU   

Appendix 1- spinal MDT decision flow chart for high risk cardiac patients 

Patients referred to Spinal MDT with 
complex cardiac conditions, significant heart 
failure, pulmonary hypertension or referred 
for ECLS back up. Discussed in JCC if not 
already done. 

Joint Cardiac Conference (JCC)- to discuss risk, need for 
specific cardiac management, suitability for ECLS and 
post op destination  

Re-discussed in Spinal MDT for final decision on 
suitability for surgery and peri-operative planning- 
flagged as high risk to Spinal CNS by PICU link  

Decision to admit to CICU 

Decision to admit to PICU 

CICU bed requested, ECLS team to 
counsel family if back up ECLS bed 
required.  Spinal CNS to liase CICU 
the week prior to surgery. 
Anaesthetic team to check bed 
availability the morning of surgery. 

PICU November 2019 

PICU bed requested and PICU link to 
discuss in PICU consultant meeting for 
dissemination of information, post op plan 
refinement. Disagreement brought back to 
spinal MDT by PICU link. If ECLS back up 
appropriate PICU link to liase with ECLS 
lead the week prior to surgery and 
anaesthetic team to check bed availability 
and ECLS capacity the morning of surgery. 

 
 
 
 
 
 
 
 
 
 
 
 
                                                                                        
 
 
                                                                                                                                                                                
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Spinal Surgery Pathway for Patients Admitted to PICU   

Appendix 2- perioperative management of spinal patients with Pulmonary Hypertension (pHTN)  

Pragmatic definition of pHTN: Any patient with the label of pHTN or on treatment for pHTN. 
Cardiology to refer to pHTN team if concerned and not previously known to pHTN team.  

Cardiology/pHTN team to decide if further vascular studies to assess pulmonary hypertension 
required  

Risk assessment and risk for surgery to be discussed in spinal MDT. Patients with pHTN not 
controlled by medication not suitable for surgery until stable.  

Cardiology/pHTN team to discuss complex patients or those referred for ECLS back up in JCC.  

Pre-op admission to PICU to stabilise on IV sildenafil 24-48hrs prior to surgery to mitigate poor 
enteral absorption post operatively. 

Echo assessment on admission pre first dose of IV sildenafil and 4-6 hours post 2nd or 3rd dose. 
Cardiology and/or pulmonary hypertension team to review pre op to check estimation of pulmonary 
pressures.  

IV sildenafil to continue day of surgery and post op until tolerating enteral feeds and medications. 
Other enteral medications for pulmonary hypertension such as Bosentan to continue throughout. 

Patients with Pulmonary Hypertension: start CVP monitoring, continue IV sildenafil with inhaled 
nitric oxide available. Optimise analgesia, avoid acidosis, avoid hypoxia (physiotherapy and 
optimising lung volumes), and avoid hypotension (whilst avoiding fluid overload). Oral sildenafil to 
be reintroduced once tolerating feeds. 

Cardiology and/or pulmonary hypertension team assessment pre-extubation to ensure estimated 
pulmonary pressures stable compared to pre-operative assessment and pre-discharge to HDU.  
Extubation once stable after first night post op during day shift. 

Patients with known pulmonary hypertension with signs of pulmonary hypertensive crisis or low 
cardiac output at any stage: Medical management optimisation as above, achieve alkalosis, high 
FiO2, inhaled nitric oxide, inotropes to achieve systemic blood pressures above pulmonary pressures 
and consider milrinone if systemic pressure allows. Urgent cardiology review and early ECLS referral 
if evidence of ongoing low cardiac output or hypoxia. 

PICU November 2019 

 
 
 
 
 
 Amy’s journey in 2018

Case reviewed at  non-quorate 
Spinal MDT, ECMO potential 
noted – decision to proceed to 
surgery

Spinal pre-assessment process 
and consent

Admission to Ward

Anaesthetist confirms PICU 
bed availability 

Operation in Theatre

Handover from Anaesthetics to 
ICU

PICU for post operative care

Extubation out of hours

Patient deterioration and 
clinical need for ECMO support 
identified

ECMO team called in from 
home

ECMO commenced  following 
assessment

What happens now

Case reviewed at quorate 
Spinal MDT and ECMO 
potential noted
Patient referred to JCC by 
Cardiology Consultant who 
attended spinal MDT
JCC assess risks and benefits 
of ECMO & confirm post 
operative location
Cardiologist feedback to Spinal 
MDT. Spinal MDT decision to 
proceed to surgery

MDT documented 
in patient record 
on Epic

Patient and family provided 
with ECMO information and 
counselling

Pre-assessment process and 
consent

Patient discussed at the PICU 
Consultants meeting

Spinal CNS high risk patient 
reminders one week before 
and on day of admission

PICU link consultant will liaise 
with ECMO team 1 week prior 
to admission regarding capacity

Admission to ward
Anaesthetist confirms PICU 
bed and ECMO availability
Operation in Theatres
Consultant level handover 
from Anaesthetics to ICU using 
structured form

PICU/CICU for post op care
PICU & CICU to notify 
perfusion of high risk patient, 
so perfusionist stays on site
Extubation in line with 
guidance/clinical need