Omarian Brooks

London Ambulance Service 
NHS  Trust 

Legal Services 
Headquarters 
220 Waterloo  Road 
London 
SE1  BSD 

Tel:  0207 783 2001 
Fax:  0207 783 2009 

www.londonambulance.nhs.uk

Your Ref: 
Our Ref : 5972 
Date  : 23 July 2020 

HMC Andrew Harris 
London  Inner South 
Southwark Coroners Court 
1 Tennis Street 
London 
SE11YD 

Dear Mr Harris 

Regulation 28:  Prevention of Future Deaths Report for Master Omarian Brooks 

Thank you  for your  Regulation  28  Prevention  of Future  Deaths  Report  (PFD)  dated  29  May 
2020. 
I  would  like  to  take  this  opportunity  at  the  outset  of  my  letter  to  offer  my  deepest 
condolences to  Master Brooks' family. 

Following the conclusion of the above inquest, the London Ambulance Service NHS Trust (LAS) 
understands from  the  PFD report that the learned  Coroner has recommended that the  London 
Borough of Lewisham, the LAS,  Sydenham Green Group Practice and  Lewisham & Greenwich 
NHS Trust work together on the issue of inter-agency working to prevent future similar deaths. 

The matter of concern for the LAS is the dispute regarding  the  conveyance to  hospital and the 
Patient Specific Protocol (PSP), which  I will address in turn: 

1.  Managing the Conveyance of Patients 

The  LAS's  position  on  conveying  patients  to  the  most  appropriate  destination  is  detailed  in 
OP/014  Managing the  Conve  ance of Patients  Policy and  Procedure.  During  the inquest you 
Sector Senior Clinical  Lead,  that this  policy was  due to  be 
were  advised  by Ms 
updated  but due to t  e curren  pandemic it has  not been possible for the  LAS  to  carry out this 
update. The LAS endeavours to update this policy by the end of October 2020. 

Given  that  this  patient  was  presenting  with  a  potentially  critical  illness,  conveyance  to  the 
nearest  emergency  department was  indicated.  The  acceptable  exceptions  to  conveying  the 
child  to  another hospital  would  not  apply  in  an  emergency  situation  save  for the  nearest unit 
not being  equipped  to  deal with  a  paediatric  patient.  This would  not have been  the  case  with 
Lewisham Hospital which  has a paediatric emergency department. 

The crew had correctly identified that the child was critically unwell and  moved to convey them 
to the nearest emergency department as per policy. 

Furthermore, during the inquest you were also advised by Ms - tha t the Policy for Consent 
to  Examination or Treatment (OP/031) will be  updated by herself.  However,  due to the current 

 pandemic Ms -was  re-deployed to frontline clinical duties and therefore it was not possible 
to carry out this  update.  However,  at the time of writing  Ms -
is  liaising  with  the  relevant 
persons  within  the  LAS  to  progress  the  update  of this  policy  and  endeavours to  update  this 
policy by the end  of October 2020. 

2.  Patient Specific Protocols (PSP) 

In  2017 the  LAS  was  operating  a  PSP  process  which  involved  the  patients'  regular clinician 
(GP or Hospital Consultant) completing paper forms detailing the specific clinical requirements 
that may be  required  for their patient's condition.  This form  was faxed  or emailed to  the  LAS, 
in  order to  provide  supplemental  information  to  the  crews  when  attending  the  patient  in  an 
emergency.  The  PSP lasted for 1 year with  the responsibility of renewing  and  updating it lying 
exclusively  with  the  clinician  who  initially  completed  it.  A  PSP  has  never  and  can  never  be 
written  by the LAS as this responsibility lies with the patients'  regular clinician. 

A  'flag'  in  the  Emergency  Operations  Centre  {EOC)  mapping  system  was  placed  so  if  an 
emergency call was  received  by the  LAS  for that  address a  little  note would  come  up  to  say 
there was a PSP.  It was  clear to the LAS that this system was not optimal for all of our patients 
so  in  collaboration  with  NHS  England  (NHSE)  and  NHS  Improvement  (NHSI)  the  LAS 
transitioned to use the Coordinate My Care (CMC) system for PSPs in  2019.  Around  February 
2018 with the roll-out of iPads, the LAS wrote to acute Trusts in  London to inform them that the 
practice of holding  PSPs within  our control  room  was  going  to  be  phased  out within  the  next 
year due to the introduction of the CMC system.  All Trusts were asked to  review existing PSPs 
and transfer them to the CMC system. 

In April 2019 the  LAS  again wrote to  acute Trusts in  London to reiterate the introduction of the 
CMC system and  asked  all  clinicians to  review existing paper PSPs  in  existence and  transfer 
them onto the CMC system by  1st  July 2019.  The transition  process was robust and overseen 
by NHSE and the Healthy London  Partnership. 

CMG  is  a  system  owned  and  governed  by  The  Royal  Marsden  Hospital  for  the  sharing  of 
specific clinical  and  patient  information  pan  London  accessible  by any and  all  Hospitals  and 
Clinicians, once they obtain log in credentials. The goal being that important clinical information 
could  be seen  by any organisation with  a single log  in  as  opposed to being  held  in  isolation  in 
multiple systems at multiple trusts or practices and therefore not visible in  a true emergency. 

Following the support from NHSE and  NHSI, CMC is now the current and only system by which 
the  LAS  is  able  to  safely,  efficiently  and  effectively  access  PSPs.  Ambulance  clinicians  now 
have  immediate access to  up  to  date  specific clinical  information  about that patient,  including 
complex issues encountered at the end of someone's life. 

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An  additional functionality that CMC  affords patients is the ability to start their own  record. This 
initial  record  is  subsequently  clinically validated  by  the  patient's  usual  clinician  in  discussion 
with the patient themselves.  This function  is called  "My CMC". 

The  CMC  team,  Healthy  London  partnership,  NHSE  and  NHSI  all  continue  to  work  with 
stakeholders to improve and refine the CMC system with the vision that it will become the single 
point of contact for detailed clinical patient information in  an  emergency pan  London. 

At  the  time  of  writing,  the  LAS's  legal  services  department  has  contacted  the  legal 
representatives  of  London  Borough  of  Lewisham,  Sydenham  Green  Group  Practice  and 
Lewisham  &  Greenwich  NHS  Trust  to  co-ordinate  a  meeting. 
It  has  been  suggested  that 

2 

 representatives  of each  agency  meet  with  t~akeholder Engagement  Manager  for 
South East London, Mr 
A mutually convenient date for such 
meeting is yet to be  agreed. 

and Ms -

I hope this  response  is  helpful in  explaining the specific actions undertaken by the  LAS. 

Yours sincerely 

Chief Executive Officer 

3

IN THE INNER LONDON SOUTH CORONER'S COURT 

IN THE MATTER 

TOUCHING INTO THE DEATH OF 

MASTER OMARIAN BROOKS 

DR_ , ON BEHALF OF SYDENHAM GREEN GROUP PRACTICE, 

RESPONSE TO CORONER'S PREVENTION OF FUTURE DEATH REPORT 

Background: 

1.  The response to the Coroner's Prevention of Future Death Report dated 29 May 2020 
are made on behalf of Dr 
an interested person pursuant to section 4 7 
(2) (g) or (m) of the Coroner's and Justice Act 2009 ("the Act"). These are made on 
and the Sydenham Green Group Practice ("the Practice"), as the 
behalf of Dr -
parties relevant to D r - to  whom a rep01t might be addressed. Dr-and the 
Practice will  be referred collectively as "the GPs" except where it is necessary to 
distinguish the two. 

2.  The Inquest took place on  10th  and 13th  January 2020 at the Inner London South 

Coroner's Coutt following the death of Master Omarian Brooks who died aged  11 
years on 28th  May 2017. The Learned Coroner has provided the Record of Inquest and 
conclusions and findings of fact on 23rd  January 2020. 

3.  The Learned Coroner in their Prevention of Future Deaths report raised matters of 

concerns: 

Matters of Concern: 

I.  The  Record concludes that had the GP been informed ofthe  boy's deterioration either 4 
days before the antibiotic was started or soon after,  he would have been admitted to 
hospital with a real prospect ofthe i,ifection being successfully treated. 

4.  The GPs have implemented a policy for circumstances where  'rescue pack'  antibiotics 
are prescribed to patients with complex needs  on a repeat basis. This policy includes 
an agreement which has to  be made between the GPs and the parents. This agreement 

 states the parents must telephone the GP Practice on the first day that they start their 
children on the antibiotics. This allows for the named GP to record in the patient's 
notes that they have started on antibiotics.  We enclose a copy of the policy to the 
response. 

5.  The GPs held a Practice Meeting on 29 June 2020 following on from  the Coroner's 
conclusion and the Prevention of Future Deaths report.  We enclose a copy of the 
Practice Meeting notes for your reference. 

6.  The GPs discussed during their meeting developing and putting in place a quarterly 
meeting to discuss children aged 5-18 with complex medical needs who are not 
discussed as part of the Health Visitor MDT aged 0-5  or the Palliative 
Care/Community MDT ages  18+. The GPs envisage that most of the Practice's GPs 
attend this and each bring a small number of cases to  be discussed. The GPs have 
scheduled to have a quarterly meeting in September 2020. 

7.  As a result ofOmarian's death, all  children who are coded as having complex needs 
have been allocated to a named GP. Therefore, any correspondence relating to these 
patients are to be brought to the attention of that named GP.  In order to ensure that 
these patients have been allocated a named GP, the GPs are planning to undertake 
audits on a monthly basis to confirm that this change has been implemented. The most 
recent audit to confirm the implementation took place on 8 July 2020 and  is  enclosed 
to this response. The named GP is also to consider discussing with the families of the 
children whether they should have a Coordinate My Care plan in place to share 
treatment plan with other services. 

8.  In situations where a GP receives a request for rescue antibiotics or similar from a 

hospital or Community Consultant, they are to clarify exactly what is being covered 
and ask the Consultant to send a shared care style agreement to formalise the 
arrangement. 

9.  Following the Practice Meeting a search for children with multiple complex needs 

was unde1taken and identified eight children within the Practice. Further examination 
of their notes was undertaken to ensure that the code 'has a carer' was recorded, and 
then cross referenced with their registered parents/guardians so that in  each of their 
notes, it was coded that they were 'a carer'. Each child was then allocated a named 
GP. The GP was informed, and it was highlighted as an alert on the child's records. 

10. The named GP, as  per the recommendations received from Lewisham Clinical 

Commissioning Group, was also changed to align with their allocated named GP for 
this purpose. The search is run every month during the Children Safeguarding MDT 
meeting. Since the GPs have started this process, one further child has been added to 
the register. The GPs hold the register of children with named GPs in a shared drive 
that is accessible to all clinicians. 

 11. D r - provided a witness statement to the Coroner at the Inquest in January 2020. 
Dr -submitted an Action Plan which the GPs had formulated following the 
Serious Case Review on 4 July 2019. The GPs has now implemented the changes 
proposed in the Action Plan, in particular, that children with complex needs are to 
have at least one named GP.  We enclose a copy of the completed Action Plan to this 
response. 

2.  There was also a distressing dispute between the ambulance crew and parents as to 

which hospital Omarian should be taken,  in the event he was not taken to  the nearest 
hospital at the insistence ofhis parents (although in this instance the delay was not found 
to have contributed to  the death). 

12.  The Coroner comments in their PFD report under 'Action Should Be Taken' that 

"Accordingly these agencies and the local hospital are the subject ofthe report as in 
my opinion their joint action should be taken to prevent future deaths." In light of the 
Coroner's concerns, a multi-agency meeting took place on 14 July 2020. The purpose 
of the multi-agency meeting was to discuss the PFD Report and the concerns raised 
by the Coroner in order for a joint response to be prepared. 

13. During the multi-agency meeting Dr-was able to feedback to the agencies what 
changes have been implemented at the Practice following the Coroner's conclusions, 
such as, the new Practice policy regarding antibiotics and the named GP system for 
children with complex needs. By updating the other agencies,  it enabled for further 
discussions to be generated about how they could  impact on the changes made by the 
GPs. For example, there was a discussion with Lewisham CCG in respect of every 
Practice across Lewisham having a designated GP for children with complex needs. 

14. There were also lengthy discussions during the multi-agency meeting in  respect of 

'Coordinate My Care'. This has been raised by other agencies as a way to have access 
to patient information from different agencies. The Practice has CMC embedded into 
their medical records system. The GPs have been using CMC regularly since its 
inception in 2015 for adult patients as a platform to share medical information with 
outside agencies such as London Ambulance Service,  111  and the local hospice. 
Unfo1tunately, the CMC was not available for children during the time of Omarian's 
life. The GPs report that CMC is now available for children under the age of 18.  The 
GPs have subsequently worked through CMC already with one family  in the practice 
who have specific medical needs and will continue to offer it to all  patients going 
forward. 

15. As the GPs now allocate patients with complex needs to a named GP this  means that 

there is a point of contact for CMC. This will allow for better communication between 
the different agencies. Therefore, if there are any requirements such as a specific 
hospital which the parents have requested then that can be made clear to other 
agencies involved in the patient's care. 

 Summary 

16. The GPs have worked hard to implement changes to ensure that the concerns which 
have been raised by the Coroner have been addressed. The Coroner had concerns in 
respect of the GP's lack of awareness that Omarian had started a course of antibiotics 
and were also  unaware ofOmarian's subsequent deterioration. The Practice want to 
guarantee that where there are cases similar to Omarian' s that the appropriate safety 
netting measures are in  place. 

17. There were important discussions at the multi-agency meeting which were greatly 
beneficial for the GPs. It allowed for there to be discussions relating to  how the 
Practice can implement changes and how other agencies can support those changes. 
The Learned Coroner will note that a multi-agency response has been formulated 
which gives an overview of how each agency has implemented their own changes and 
also how they are working together to  ensure there is  effective co-ordination between 
the different agencies. The GPs are committed to having a coordinated multi-agency 
approach to future patients. 

5 August 2020 

Gordons Partnership LLP 

Edgeborough House 

Upper Edgeborough Road 

Guildford Surrey 

GUI 2BJ 

Our Ref:  LRL/MDU00 1.1118 

 GP Partners: 

Sydenham Green Group Practice 

26 Holmshaw Close,  London SE26 4TH 
Tel: 020 3049 2820 
Fax: 020 3049 2821 
Web: www.sydenhamgreenpractice.co.ujs 
E-ma iI: LEWCCG .g85024~genera l@n hs. ne~ 

Sydenham Green Group Practice Procedures & Protocols 

Protocol for the  Prescription of "Rescue pack" Antibiotics in  Children 

Date:  July 2020 
Review due: January 2021 

Summary. 

The prescription and  use of rescue pack antibiotics in  children  is not a common 
occurrence. The development of this protocol is to ensure that all GPs in the practice have 
a framework to  aid  them through safe decision making  in the prescribing process. 

•  The prescription of rescue pack antibiotics will only be undertaken upon the advice 

of a secondary care clinical team. 

•  The GP will  clarify that these instructions are clear and are accompanied by a clear 

care plan. 

o  Key areas that must be  recorded and discussed with  the family are; when the 

GP is to prescribe these antibiotics, when they should be started by the 
family,  when  the family is to  inform the GP that the antibiotics have been 
started,  and  at what stage after antibiotics are commenced that follow-up by 
the GP is required. 

• 

Internal follow-up will occur within the GP practice to ensure that the named GP for 
the child  is aware that the child  has been  commenced on  the course of rescue pack 
antibiotics. 

•  Timely review of the ongoing availability of rescue pack antibiotics. Medication 
reviews are undertaken at least once yearly in  primary care. We should expect 
information from the secondary care clinician as to  whether the use of rescue  pack 
has been  reviewed by their team.  If not,  we will  no longer be prepared to carry on 
prescribing rescue pack antibiotics. 

Practice Manager 

 29th  June 2020 
Present: 
GP: 

The meeting was  held to discuss the Coroner's report into the death of Omarian Brooks  (DOB 27-02-2006, DOD 
27/05/2017). The Coroners judgement and  Preventing Future Deaths  report are below: 

Brooks0marian PFD 
V2docx.docx 

Brooks0 
Judgment.docx 

The relevant section of the PFD  report is as follows: 

ACTION SHOULD BE TAKEN 

It is  not for the court to determine whether earlier admission to hospital of potentially septic disabled children is achieved by a 
Patient Specific Protocol or Child in Need Plan or by way of mandating informing the general practice that antibiotics had 
been started, or a combination of these or other forms of multi-disciplinary care. Accordingly these agencies and the local 
hospital are the subject of the report as in my opinion their joint action should be taken to prevent future deaths.  It is not cleai;, 
that the steps taken by the general practice for  the duty doctor to inform colleagues of a consultation, nor the action plan by ·•···... : 
the Borough implementing the recommendations of the SCR, which refers to standby antibiotic usage (and not 
communications with the GP),  and does not specifically involve the London Ambulance Service can be relied  upon to prevent 
such a death recurring. Some information was submitted after conclusion of the inquest by L&G NHS Trust, which had not 
been admitted as evidence and may usefully be part of the response to the report.  I believe that these organizations would wish 
to learn of the evidence given in the inquest about the circumstances of this death and can mitigate or prevent future deaths by 
articulating their joint action. 

The suggestion is that the practice should work with other parties {London Ambulance Service, Lewisham & Greenwich NHS 
Trust) to coordinate a response. To that end NHS South East  London CCG  have been approached for support. In the interim, 
the practice has discussed the following: 

1.  Developing and putting in place a quarterly meeting to discuss children aged  5-18 with complex medical needs who 
are not discussed with as  part of the Health Visitor MDT ages 0-5 or the Palliative Care/ Community MDT ages  18+. 
It is envisaged that most SGGP  GPs attend this and each  bring a small number of cases to be discussed.  Dr -o  
coordinate the list of patients covered. 

'. 

2.  As a result of this death, all children coded as  having complex needs  have been allocated to a named GP.  Letters for 
these patients are to be brought to the attention of that named GP  as they are found.  The named GP  is  also to 
consider discussing with the families of the children whether they should have a Coordinate My Care  plan in  place 
to share treatment plans with other services. 

3.  Where a GP  receives a request for rescue antibiotics or similar from a hospital or community consultant they are to 
clarify exactly what is  being covered and ask the consultant to send  a shared-care sty!e agreement to formalise the 
arrangement. 

4.  Drllllis to approach the CCG,  LAS  and UHL to organise a meeting to discuss a more systemic response as  the  _' 

steps above would need to be acted on in a borough/SEL-wide basis to have a meaningful impact. 

',, 

 Lewisham 
Clinical Commissioning Group 

8th  January 2020 

Letter to General Practitioners, 

Dear Colleagues, 

I write to draw your attention  to the recommendations of a Serious Case Review 
undertaken by Lewisham Safeguarding Children  Board. 

The review was undertaken following  the sad death of an  11  year old  boy who did 
not survive a cardiac arrest while on  transfer to  hospital. He and  his family were 
known  to social, primary,  secondary and tertiary services due to  his complex medical 
and health needs and there had  been  known  concerns around the  relationship 
between  health partners and the  child's carers. 

The findings of the review panel identified learning for all agencies involved  in the 
care of the child. The two key recommendations for GP  practices across Lewisham 
borough are shared here: 

•  The importance of a co-ordinated approach for children  with complex needs. 
This resonates with other Serious Case Reviews both  locally and nationally. 

In  order to support a coordinated approach  it is  a recommendation of the  review that 
a child with complex health needs has one or two named GP's identified within their 
registered  practice. This will provide continuity of care for the child and carers and 
help practices to have clear oversight of the care provided. 

• 

In  addition  it was recognised that a conscious process needs to be in  place to 
consider the health of carers of a child with complex medical and  health 
needs and  how this will impact on the outcome for children. While a full 
medical for such carers is best practice, we recognise this is currently not 
commissioned.  Lewisham CCG will raise this issue with  NHS England. 

In  the meantime, we ask that you  are mindful of the health of such carers in  your 
contacts with children,  in  order to  have a clear picture of the lived experience of the 
child. 

We would  be  grateful if these two recommendations taken  on  board  and processes 
put in  place to  implement them and  improve the outcomes for children with  complex 
medical and  health  needs 

Yours sincerely 

Director of Nursing and  Quality 

 Date of Last Search 

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08/07/2020 

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23/05/2009  WM 
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12/08/2010  MW 
24/08/2006  NH 
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10/11/2005 AK 
10/06/2014  ES 
29/01/2019 JP 

 I RECOMMENDATION 

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family meetings over 
a 6 month period to 
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actions from the 
meetings are being 
taken. 

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whether children with 
complex needs have 
parents identified as 
carers 

I A clear protocol of 
following  up  on 
children on the 
emergency duty list 
where a GP is  unable 

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Children with 
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Lewisham 
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NHS CCG 

Letter to inform GP 
practices of this 
recommendation  has
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signed off by
Director of Quality and 
Nursing for Lewisham 
CCG 

Letter to NHS England 
re commissioning of 
health  checks has been
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Inclusion of themes 
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child  safeguarding 
training  in  Lewisham  material on 

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2 MONTHS 

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5-11 Theobalds Road 
London 
WC1X 8SH 
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Phone: 020 7092 6171 
clinical.standards@rcpch.ac.uk 
www.rcpch.ac.uk 

Wednesday, 01 July 2020 

Sent by email to: 

@southwark.gov.uk 

Dear Coroner A Harris 

Re: Master Omarian Brooks 
Regulation 28 – Action to Prevent Future Deaths 

I have read carefully your report regarding the tragic and untimely death of 
Omarian Brooks and have discussed this with senior colleagues within the 
RCPCH in order to respond to your request. 

You have asked us to consider how to offer advice on mitigating such tragedies 
and I would like to offer the following response. 

COMMUNICATION AND CARE PLANNING 

•  Children with complex disability should have a named neurodisability 
paediatrician responsible for regular review, and to provide health 
information for developing health care plans. This will include plans for 
management in different settings and done in conjunction with the 
education health care plans, with plans for management in school, at home, 
in respite care, and for transport and emergency situations. Plans should 
be developed with parents and carers, and by those providing the care in 
different settings, and should be shared with primary care teams. 

•  RCPCH standards for emergency care1  describe the importance of linking 
emergency care settings with specialist nurses and community children’s 
nursing teams to ensure effective planning and follow-up. 

•  Whilst we do not have all the details or specifics of the case, a breakdown 
in communication between the parents and health professionals involved 
in Omarian’s care may have occurred. The College will continue to signpost 
and develop courses that focus on ensuring awareness of communication 
issues in relation to children with disability, all of which emphasise the 
importance of listening to parents and of ensuring patient-centred care. We 

1 https://www.rcpch.ac.uk/sites/default/files/2018-06/FTFEC%20Digital%20updated%20final.pdf 

Charityin England and Wales: 1057744 
-
PATRON HRH The Princess Royal 

Registered charity in Scotland SCO38299 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
  
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
  
  
 
  
 
 
 
 
 
 
	
 • 

have developed toolkits with children and young people with a hidden 
condition or illness to help raise awareness of conditions and support 
services2. 
In 2018, the College brought together the Royal College of General 
Practitioners, Royal College of Nursing, Royal College of Physicians and 
Royal College of Psychiatrists to develop Facing the Future: Standards for 
children with ongoing health needs3  to ensure connectivity between 
services, with a focus on improving long term care and management so 
that care is planned and proactive - particularly with improving 
communication and education for both the child and family, and 
communication between professionals. 

•  The standards recommend that service planners, providers and 

commissioners work together to ensure children and young people 
experience a high-quality and safe service that empowers children and 
their families to access timely care for the management of their condition. 
This includes ensuring a prompt and timely diagnosis with local networks 
improving communication between professionals so that children and 
families are supported to manage their conditions. 

•  The College has a published position on information sharing and maintains 

that having a unique, consistent identifier for children will allow 
professionals interacting with children to share information easily and 
provide better care for their needs.4 

SEPSIS: RECOGNITION AND MANAGEMENT 

•  The College and NHS Improvement developed a framework with clinicians 
and experts to improve recognising and responding to children at risk of 
deterioration5. This was in response to research showing that failures to 
recognise and treat patients whose condition was deteriorating causes 
significant unintended harm. 

•  The College has also developed free to access paediatric sepsis podcasts 

that have been designed as educational resources for health and social care 
professionals. They explore what sepsis is, the complexities of how to 
recognise and manage sepsis, what is different about sepsis in children 
with complex health conditions and much more6. 

•  The College is also working with NHS England and the Royal College of 
Nursing to develop a systematic paediatric early warning system, to 
develop a consistent approach and common language to promptly recognise 

2  https://www.rcpch.ac.uk/resources/hidden-health-parent-led-card-toolkit 
3  https://www.rcpch.ac.uk/sites/default/files/2018-
04/facing_the_future_standards_for_children_with_ongoing_health_needs_2018-03.pdf 
4 https://www.rcpch.ac.uk/resources/nhs-number-unique-identifier-children-position-statement 
5 https://www.rcpch.ac.uk/resources/safe-system-framework-children-risk-deterioration 
6 https://www.rcpch.ac.uk/resources/paediatric-sepsis-podcasts 

Charityin England and Wales: 1057744 
-
PATRON HRH The Princess Royal 

Registered charity in Scotland SCO38299 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
   
 
 
 
 
  
 
 
 
  
 
  
 
  
 and respond to the acutely ill or deteriorating infant, child or young 
person. 

Thank you for raising this important case and reminding us of the importance 
of this work. 

Yours sincerely 

Professor 
President, Royal College of Paediatrics and Child Health 

Charityin England and Wales: 1057744 
-
PATRON HRH The Princess Royal 

Registered charity in Scotland SCO38299