Esma Guzel

Dr Dominic Bell 
Assistant Coroner Hull and the East Riding of Yorkshire 

By Email: 
Our reference: LT04121 

Dear Dr Bell 

Inquest into the death of Esma Guzel 

7&8 Wellington 
Place 
Leeds 
West Yorkshire 
LS1 4AP 

26th July 2022 

I am writing  in response to the Regulation 28 report received from HM Senior Coroner, dated 1st 
June 2022. This follows the death  of Esma Guzel  who  sadly  passed away  on  10th May 2019. 
This  was followed  by an  investigation  and  inquest  which  concluded on 23rd March 2022, and  
which NHS Pathways gave evidence at.  I am Dr 
 and am writing in my capacity 
as Chief Clinical Officer, NHS Pathways, NHS Digital. 

NHS  Pathways  is  the  clinical  decision  support  software  (CDSS)  used  by  all  111  service 
providers, and some 999 ambulance trusts in England. For information, we have included a 
short  summary  of  the  functions  that  NHS  Pathways  performs  and  the  governance  that 
underpins it (containing background information on NHS Pathways) in Appendix A. 

I would like to reiterate my sincerest condolences to the family of Esma Guzel. 

HM Coroner  has raised the following matters of concern with regards to NHS Pathways: 

1.  The 111 algorithm has been subject to modification in the light of these events, but I 

remain concerned that there is 

a.  no detailed assessment of the degree of parental concern, 

b.  no accommodation of the prior direct review by a general practitioner, 

c.  and  no  consideration  of  the  timing  of  the  request  for  advice,  when  reaching  a 

disposition that does not involve referral to paediatric services: and 

2.  I  have  heard  in  evidence  that  an  educational  message  on  ‘rare  causes  for  common 
symptoms’  could  be  circulated  as  a  case  report,  but  take  the  view  that  the  lead 
professional bodies for both general practice and child health should consider how such 
information  is  effectively  disseminated,  and  whether  the  algorithms  and  dispositions 

www.digital.nhs.uk 
enquiries@nhsdigital.nhs.uk 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 generated  by  the  111  service  need  further  modification  to  maximise  the  chance  of 
expedited optimal care for what is acknowledged to be an uncommon condition. I have 
heard  in  evidence  that  the  111  service  is  the  default  safety  net  arrangement  in  such 
circumstances, and this therefore requires endorsement by your professional bodies, if 
it  is  to  command  the  confidence  of  patients,  parents  and  practitioners  as  a  definitive 
safety net. 

NHS DIGITAL’S RESPONSE  

To specifically address the concerns raised: 

1)  The 111 algorithm has been subject to modification in the light of these events, 

but I remain concerned that there is: 

a.  no detailed assessment of the degree of parental concern 

NHS Pathways currently has a question that considers parental concern within the context of 
other signs of general illness that result in an inability to perform normal activities (known as 
‘functional impairment’).  The supporting information for this question (visible to health advisors) 
states,  “The  individual  or  the  carer  may  feel  that  something  is  seriously  wrong”.  Answering 
positively  to  this  answer  stem  would  be  a  positive  response  to  functional  impairment.  This 
feature is included within the “vomiting blood pathway” for children aged over 5 and under 16 
years old (as well as many other pathways). In this pathway the combination of the answers to 
the questions will result in a disposition which is mapped to  either a Category 3 ambulance, 
‘Primary Care within 1 hour’ or ‘Primary Care within 2 hours’. The lowest level of care within 
the  vomiting  blood  pathway  for  children  aged  over  5  and  under  16  years  old  is  mapped  to 
‘Primary  Care  within  2  hours’  for  further  assessment  by  a  clinician.  Please  see  below  for  a 
screenshot of the ‘functional impairment’ question.  

www.digital.nhs.uk 
enquiries@nhsdigital.nhs.uk 

 
 
 
 
 
 
 
 
 Assessing parental concern through telephone triage is challenging as it is highly variable and 
subjective,  with  other  discriminators  such  as  physical  signs  of  organ  dysfunction  provide 
stronger discriminatory accuracy for severe illness in most cases.   NHS Pathways therefore 
assesses parental concern as described above and this, in the context of other symptoms also 
presenting,  is  taken  account  of  in  the  disposition  reached.    It  is  critical  that  an  Urgent  and 
Emergency care triage system such as NHS Pathways ensures that patients’ symptoms are 
assessed in a timely manner so that the appropriate level of care can be offered rapidly and 
safely.  NHS  Pathways  considers  that  providing  a  more  detailed  assessment  of  parental 
concern at this stage of the triage would be challenging for a health advisor and may result in 
delays in signposting to the next level of care. 

Esma’s  case  was  thoroughly  reviewed  by  the  NHS  Pathways  team  to  identify  any  potential 
learning and, following this, changes were made to the vomiting blood pathways to improve the 
identification  of  ‘critical  illness’.  The  potential  critical  illness  triage  assessment  includes 
additional  questions  on  breathlessness  and  confusion.  These  additional  questions  offer 
increased sensitivity to detect how unwell a child is and detect organ dysfunction and potential  

deterioration. 

Had  these  critical  illness  triage  assessment  questions  been  asked  as  part  of  Esma’s 
assessment,  if  symptoms  of  breathlessness  and  confusion  were  identified,  the  disposition 
reached would have been a Category 3 ambulance. A Category 3 ambulance means that 90% 
of incidents are responded to within 2 hours.  

The above changes were approved by members of the National Clinical Governance Group 
(including The Royal College of Paediatrics and Child Health) as being a sensitive marker of 
critical illness in children and made within the system in Release 29 which was initially deployed 
through ‘early adopter testing’ on 1st November 2021, then widescale deployment from 24th 
November 2021. 

b.  no accommodation of the prior direct review by a general practitioner 

NHS Pathways assesses symptoms at the time of the call. If all patients who had a previous 
encounter with a healthcare provider were automatically transferred to a clinician this would 
prevent the initial NHS Pathways assessment occurring which has the potential to prevent a 
timely  generation  of  an  urgent  disposition  such  as  an  ambulance  dispatch.    It  is  also  not 
possible to interrogate previous encounters as part of the NHS Pathways assessment such to 
only  transfer  some  to  a  clinician,  as  this  would  require  reliance  on  caller’s  recollection  and 
knowledge,  and  health  advisors  to  use  discretion,  neither  of  which  is  clinically  safe  or 
appropriate for telephone triage by non-clinical staff.  Furthermore, previous direct review by a 
healthcare provider can represent a highly variable set of scenarios that has the potential to 
undermine  the  triage  of  the  symptoms  at  the  time  of  assessment  and  result  in  the  wrong 
disposition  with  subsequent  clinical  risk.  The  fact  of  and  details  of  these  contacts  may  be 

www.digital.nhs.uk 
enquiries@nhsdigital.nhs.uk 

 
 
 
 
 
 
 
 
 relevant to the assessment of symptoms at the time of a later call, but this is not always the 
case. 

NHS  Digital  does  not  consider  that  all  paediatric  cases  where  there  has  been  previous 
attendance to primary or secondary care should result in transfer of the call to a clinician. It 
considers  that  doing  this  could  cause  potential  delays  to  assessing  patients  which  could 
compromise patient safety. The system deals with a significant number of calls to 111 which 
have followed a previous assessment by a GP or other health care provider (or have also been 
previously  assessed  by  a  111  or  999  service  and  advised  to  call  back  should  a  condition 
deteriorate). Providing a higher disposition than reached upon symptom-based-triage for those 
where there has been a previous contact with a healthcare provider may introduce delays to 
provision of care for individuals and across the population. 

Recent prior contact with 111 service itself is taken account of as follows.  The NHS 111 service 
specification (which can be found in full here: 

https://www.england.nhs.uk/urgent-emergency-care/nhs-111/nhs-111-service-specification/ 

states: 

“If a patient (or their carer) calls NHS 111 three times in 4 days, on the third call the patient 

must be assessed to determine whether or not an ambulance is required. If an ambulance is 

not  required  the  call  must  be  transferred  to  a  clinician.  The  GP  must  complete  a  thorough 
reassessment of the patient’s needs and have access to the details of all three calls”. 

This  specification  is  set  by  NHS  England  and  further  questions  regarding  the  rationale  for 
setting this requirement would be best dealt with by NHS England. 

c.  and no consideration of the timing of the request for advice, when reaching 

a disposition that does not involve referral to paediatric services 

NHS  Pathways  is  a  comprehensive  decision  support  system,  which  assesses  symptoms 
presented at the time of a call and signposts to next level of care. Therefore, assessment of 
time of day is not routinely considered as it would not be clinically safe to change level of care 
signposted  to  be  based  upon  time  of  day  as  a  discriminator  alone.  However,  the  functional 
impairment  question  identifies  when  the  presenting  problem  is  interfering  with  normal  daily 
activities and that would include sleeping. This is an assessment against the patient’s ‘usual 
activities’  so  takes  account  of  different  patients  having  different  baselines.  In  addition,  NHS 
Pathways must consider differing daily routines encountered and ‘usual activities’ at different 
times of day may differ from person to person. For this reason utilising an objective standard 
against the individuals ‘usual activities’ is the preferred approach. 

www.digital.nhs.uk 
enquiries@nhsdigital.nhs.uk 

 
 
 
 
 
 
 
 
 
 NHS  Pathways  assessments  result  in  a  disposition,  but  it  is  a  local  responsibility  to  match 
services  to  these.    Therefore,  services  which  are  presented/returned  from  the  Directory  of 
Services for urgent primary care assessment (including Out of Hours referrals) are determined 
by  local  commissioners,  and  local  decisions  can  be  made  not  to  make  certain  services  or 
locations available in response to paediatric dispositions.   

2)  I have heard in evidence that an educational message on ‘rare causes for common 
symptoms’ could be circulated as a case report, but take the view that the lead 
professional  bodies  for  both  general  practice  and child  health  should consider 
how such information is effectively disseminated, and whether the algorithms and 
dispositions generated by the 111 service need further modification to maximise 
the  chance  of  expedited  optimal  care  for  what  is  acknowledged  to  be  an 
uncommon condition. I have heard in evidence that the 111 service is the default 
safety  net  arrangement  in  such  circumstances,  and  this  therefore  requires 
endorsement by your professional bodies, if it is to command the confidence of 
patients, parents and practitioners as a definitive safety net. 

RCPCH and RCGP have agreed to respond to this concern. 

Conclusion 

•  NHS Pathways is not a diagnostic system; it assesses symptoms presented at the time 
of the call and signposts to the care skill set and time frame that a patient requires at 
that  point  in  time.    For  this  reason  prior  health  care  contacts  are  not  taken  into 
consideration other than repeat, recent 111 calls. 

•  Parental concern is taken account of in functional impairment assessment. 

• 

It  is not  clinically  safe  or  recommended  to  vary  dispositions  by  time  of  day,  but  local 
decisions can be made in respect of the mapping of services to dispositions.   

•  The NHS Pathways content is continually under review to take account of clinical issues, 
user feedback, the latest available data and evidence, guidelines from Royal Colleges 
and  other  respected  bodies  and  Coroner  feedback.  Any  changes  to  NHS  Pathways 
clinical content are overseen by the National Clinical Governance Group (NCGG) and 
Coroner referrals are submitted to NCGG as a standing agenda item. 

NHS Digital takes its role in such enquiries and any PFD report received very seriously. NHS 
Digital  wish  to  reassure  the  Coroner  that  it  fully  investigates  and  responds  to  PFD  Reports 
accordingly. The matters that concerned the Coroner have been further assessed, and NHS 
Digital hopes this response assures that any changes that can be made to better the service 
and  make  this  safer  in  respect  of  this  points  have  been  made.  If  I  can  be  of  any  further 
assistance, please let me know. 

www.digital.nhs.uk 
enquiries@nhsdigital.nhs.uk 

 
 
 
 
 
 
 
 
 
 I would like to take this opportunity again to offer my sincere condolence to Esma Guzel’s family.  

Yours sincerely 

Chief Clinical Officer NHS Pathways 
NHS Digital 

www.digital.nhs.uk 
enquiries@nhsdigital.nhs.uk 

 
 
 
 
 
 
 
 
 
 
 
 Function of NHS  Pathways 

Appendix A 

NHS Pathways is a telephone and digital triage Clinical Decision Support System (CDSS) that has 
been in use since 2005 within the Urgent and Emergency care setting. It is used in all NHS 111 and 
half of English ambulance services. This triage system supports the remote assessment of over 19 
million calls per annum.  

NHS  Digital  is  the  Health  and  Social  Care  Information  Centre  (a  non-department  public  body)  as 
detailed in Part 9, Chapter 2 of the Health and Social Care Act 2012. The NHS Pathways system is 
owned by the Department for Health and Social Care, commissioned by NHS England and developed 
and managed by NHS Digital; the NHS Pathways team is part of NHS Digital.  

Calls using NHS Pathways are managed by non-clinical specially trained ‘Health Advisors’ who refer 
the patient into suitable services based on the patient’s health needs at the time of the call. The Health 
Advisors are supported by clinicians who can provide advice and guidance or who can take over the 
call if the situation requires it.  

The system is built around a clinical hierarchy, meaning that life-threatening symptoms are assessed 
at the start of the call triggering ambulance responses, progressing through to less urgent symptoms 
which require a less urgent response (or disposition) in other settings. NHS Pathways is not a diagnostic 
system and only assesses symptoms presented at the time of the call and signposts to next level of 
care.  

NHS Pathways is an interlinked series of algorithms, or pathways, that link questions and care advice 
leading to clinical endpoints known as “dispositions”. The system presents a series of questions in order 
that the most appropriate clinical response or disposition may be determined based on the answers 
given. A disposition will specify the skill set and time frame that a patient requires. The system triages 
both injury and illness presentations for all age groups (neonate, infant, toddler, child, and adult). In 
addition, special populations are included where relevant to the triage e.g., pregnancy. 

The NHS Pathways system was developed and maintained by a group of experienced NHS clinicians 
(clinical  authors)  with  an  Urgent  and  Emergency  Care  background.  The  NHS  Pathways  clinical 
authoring team come from a variety of clinical backgrounds and are either a paramedic, nurse or doctor 
who are registered, licensed practitioners. 

Governance  of NHS Pathways 

The safety of the clinical triage process endpoints resulting from a 111 or 999 assessment using 
NHS  Pathways,  is  overseen  by  the  National  Clinical  Governance  Group,  an  independent 
intercollegiate group hosted by the Royal College of General Practitioners. This group is made 
up  of  representatives  from  the  relevant  Medical  Royal  Colleges.  Senior  clinicians  from  the 
Colleges provide independent oversight and scrutiny of the NHS Pathways clinical content. The 
group considers all aspects of the triage process, including the impact on services, as well as 
the evidence base for changes to the clinical content. All changes to, and development of, the 
core  telephone  system  and  other  platforms,  are  formally  documented  and  presented  for  a 
critique by a group of authors. This includes both purely clinical elements, but also an appraisal 
of the operational impacts on NHS Pathways users and on providers’ services. 

www.digital.nhs.uk 
enquiries@nhsdigital.nhs.uk 

 
 
 
 
 
 
 
 
 
 
 
 Alongside  this  independent  oversight,  NHS  Pathways  ensures  its  clinical  content  and 
assessment protocols are consistent with the latest advice from respected bodies that provide 
evidence and guidance for clinical practice in the UK. This includes latest guidelines from: 

a. NICE (National Institute for Health and Clinical Excellence); 
b. The UK Resuscitation Council; and 
c. The UK Sepsis Trust. 

Safe and appropriate use of NHS Pathways by NHS care providers is governed by way of a 
‘Licence to Use’. 

NHS Pathways welcomes user feedback to help improve the system. The License to Use details 
how serious incidents, near misses, requests for change, suggestions for enhancements and 
inquests or Prevention of Future Deaths Reports relevant to NHS Pathways should be reported 
to NHS Digital via the NHS Pathways authoring tool (in redacted form). Such clinical enquiries 
are given a priority grade and reviewed and responded to accordingly. All providers have access 
to the log and can see all enquiries raised. 

www.digital.nhs.uk 
enquiries@nhsdigital.nhs.uk

KS Royal College of

GP General Practitioners

Dr MD Dominic Bell
Assistant Coroner for Hull and the East Riding of Yorkshire

Sent - email to:

Dear Dr Bell,

26 July 2022

Regulation 28 Report to Prevent Future Deaths - touching on the death of Esma Guzel

| write as Honorary Secretary for the Royal College of General Practitioners (RCGP), in response
to your Regulation 28 report dated 1 June 2022, regarding the very sad death of Esma Guzel.
May | offer my sincere condolences to Esma’s family.

The RCGP is a professional membership body for general practitioners in the UK and overseas.
Our purpose is to encourage, foster and maintain the highest possible standards in general
medical practice. We support GPs through all stages of their career, from medical students,
through to training, qualified years and retirement.

Your report has been reviewed and considered by our clinical policy team, our medical director
for clinical policy and myself and we have discussed the details with our colleagues in the Royal
College of Paediatrics and Child Health.

Details provided

The Regulation 28 report identifies a young 5-year-old child presenting with vomiting and
abdominal pain. This is extremely common in primary care and the report suggests a provisional
diagnosis of gastroenteritis was made, and that the GP gave safety netting advice. This would be
standard care for any child who presented with similar symptoms and did not have an acute
abdomen or signs of sepsis requiring admission to hospital as determined by NICE guidance
from 2017.

Comments
You have asked us to consider the facts of the case and determine what action should be taken
to prevent future deaths of this kind. Given that we do not have all of the facts of the case, we

are unable to comment of the specifics off the individual consultations undertaken with Esma
and her family, but | am able to lay out the educational material the RCGP has for GPs in training
before they are able to work as a qualified GP.

GP in training curriculum

Paediatrics and child health is covered extensively in the RCGP curriculum which contains a
‘Children’s and Young People’ specific curriculum that all GPs in training follow. This includes
several areas that would relate to this case including common and important conditions such as
paediatric emergencies, congenital abnormalities, gastrointestinal conditions that present in
childhood, age-appropriate examinations and liaising with colleagues for complex disease. GPs in
training would be assessed on their knowledge of this aspect of the curriculum in workplace-
based assessments, the applied knowledge test (a written exam) and in a recorded consultation
assessment before a GP trainee could qualify and work independently as a GP.

In addition, we have extensive educational material on remote consultations including both
telephone and video consulting to help GPs and their teams undertake the best possible
assessment and determine whether a face to face review is required. We also have available our
“Sepsis toolkit” which identifies the sick child in line with national guidance.

Qualified General practitioners

As part of the nationally mandated appraisal system, GPs must undertake annual appraisal and
revalidate every 5 years. The Academy of Medical Royal Colleges released its updated guidance
in June 2022 describing how GPs and indeed all medical doctors must on an annual basis
demonstrate evidence of continuing professional development. The General Medical Council
describes the evidence required at the appraisal including proof of “keeping up to date”, and
“maintaining and enhancing the quality of your professional work”.

Important messages for primary care
General practitioners must have a broad breadth of general knowledge for both adults and
children, which would include identification of an acutely sick child, recognition of sepsis and
recognition of an “acute abdomen”. The specific cause (rare or otherwise) of the acute abdomen
is often not of importance in primary care, it is the recognition of the acute abdomen and sepsis,
irrelevant of the cause that matters as this would trigger a referral to secondary care, where the
specialist teams would then identify the cause. For this reason, a “rare cause case report” is
unlikely to alter practitioners care pathways in primary care.
The key messages required for general practitioners and their teams are therefore

e recognition of sepsis/ the sick child and

e recognition of the acute abdomen

Importantly, in the acute stages of any illness, when the definitive diagnosis is not clear, as often
happens in primary care with undifferentiated presentations, safety netting is undertaken, as per
NICE guidance. This means that if the person does not meet the criteria for admission, then they
(or the carer) are given advice on what to do if the patient gets worse, does not get better, or
suddenly deteriorates whilst at home. In this case, it appears that Esma deteriorated 8 hours
after the GP consultation, requiring out of hours contact, after the GP surgery was closed.

The only options at this time for the family would have been to call 111, call 999 or to go directly
to A&E.

111 algorithm

The 111 algorithm sent the child to a GP out-of-hours service, rather than calling an emergency
ambulance or advising urgent attendance to accident and emergency. [he NICE guidance and
stratification tool for recognition of sepsis on the out of hospital environment for age 5-11 give
clear indication which children should be sent to A&E, and we note that the 111 algorithm has
been altered following this case which we welcome.

Sharing of data/ clinical notes between primary care and the out-of-hours service

There are some out-of-hours services who are able to see the whole GP record. It does not
appear in this case it was possible from the Regulation 28 report. If both the out-of-hours service
and the GP surgery use the same electronic notes system it is possible, with patient consent, to
share all of the GP record. However, in many areas, the GP record is not visible to the out-of-
hours service as both use different digital platforms. The RCGP would welcome investment in
primary care (both GP and out-of-hours services) infrastructure, to enable best practice of
sharing of all notes, subject to patient consent, to be rolled out across the NHS to benefit patient
care. However, we recognise this will require significant investment form NHS England and NHS
Improvement and the Department of Health and Social Care.

Conclusion
Thank you for raising this important case with us. We will continue to review our e learning offer
for our members and if national guidance changes, update them accordingly. At the current time,
a rare case report dissemination is not considered to be needed for primary care as the key
messages are identifying the sick child,

e identifying sepsis and

e identifying the acute abdomen

We welcome the changes made to the 111 out-of-hours algorithm and hope that the system can
learn, to prevent anything like this happening again.

Please do let us know if you require any further information and once again, may | offer my
sincere condolences to Esma’s family.

Yours Sincerely

RCGP Honorary Secretary

5-11 Theobalds Road  
London  
WC1X 8SH  
- 

- 

25 July 2022 

Dr Dominic Bell 
Assistant Coroner 
Hull and the East Riding of Yorkshire 

Dear Dr Bell 

Re: Esma Guzel, aged 5 years 

Thank you for sharing your Letter of Concern with us regarding the tragic and untimely death of 
Esma Guzel. We were saddened to read the circumstances surrounding this child’s passing and 
have discussed with senior colleagues within the RCPCH and with the RCGP.  

You have asked us to:  

•  consider the facts of the case 
• 

form a view on whether educational messages on ‘rare causes of common symptoms’ 
should be circulated to our members 
form a view on whether the algorithms generated by the 111 service need further 
modification to prevent a future death of this kind.  

• 

The RCPCH is a professional membership body responsible for training and examining 
paediatricians, setting professional standards and informing research and policy for children’s 
health services and the paediatric workforce. Given that we do not have all the details of the 
investigation, the RCPCH is unable to comment on the specifics of the case.    

In considering the information that we do have about this case, I am pleased to set out below the 
standards of care that we would expect from local service planning, and other work from the 
RCPCH where we feel a difference can be made.  

Facing the Future – standards for paediatric care  

Together for Child Health 

These standards1 apply across the unscheduled care pathway to improve healthcare and 
outcomes for children. They focus on the acutely mild to moderately unwell child and were jointly 
developed with the Royal College of Nursing and Royal College of General Practitioners.  

The overarching principles agreed when developing this work that are relevant to the context 
surrounding this child’s passing are as follows:  

•  every child should have timely access to high-quality unscheduled care services that are 
safe, effective and caring, that promote good health and wellbeing and that reduce the 
impact of illness on the child and their parents and carers 

•  service providers, planners and commissioners to work together across hospital and 

community services, primary and secondary care and paediatrics and general practice to 
design and deliver efficient and effective unscheduled care in a geographical network 
which is responsive to the needs of local children and their parents and carers. 

 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
 
 
 
 A summary of standards that we feel are most relevant to ensuring children receive safe and 
timely unscheduled care include:  

•  GPs assessing or treating children with unscheduled care needs have access to 

immediate telephone advice from a consultant paediatrician. 

•  Each acute general children’s service provides, as a minimum, six-monthly education and 
knowledge exchange sessions with GPs and other healthcare professionals who work 
with children with unscheduled care needs. 

•  Children presenting with unscheduled care needs and their parents and carers are 
provided, at the time of their discharge, with both verbal and written safety netting 
information, in a form that is accessible and that they understand. 

•  Acute general children’s services work together with local primary care and community 

services to develop care pathways for common acute conditions. 

•  There are documented, regular meetings attended by senior healthcare professionals 

from hospital, community and primary care services and representatives of children and 
their parents and carers to monitor, review and improve the effectiveness of local 
unscheduled care services. 

We have collected some best practice examples2 on our website to share and encourage 
innovation across local service planning and delivery. We anticipate local discussions around 
urgent care pathways to gather momentum as the Health and Care Act in England has 
formalised the creating of Integrated Care Boards (ICB). The creation of an executive children’s 
lead on each ICB will provide leadership and accountability for the important service issues in 
child health.  

Standards for children and young people in emergency settings 

These standards3 aim to ensure that urgent and emergency care is fully integrated to ensure 
children are seen by the right people, at the right place and in the right setting. As the standards 
document describes, the future of urgent and emergency care for children is dependent upon 
building whole system networks that harness expertise within the subspecialty of paediatric 
emergency medicine that links across all urgent care and community settings.  

Developing robust care pathways, building capability amongst professionals (such as GPs, 
health visitors, pharmacists and paramedics), and providing seamless links via intuitive 
governance and information sharing platforms will enable children to be managed by the right 
person, in the right place, at the right time and as close to home as is possible and safe to do so. 

Paediatric Early Warning System and safety netting 

We are collaborating with NHS England and the Royal College of Nursing to develop a single 
nationally validated Paediatric Early Warning score and system, (PEWS) for England. In 2020, 
the NHS SPOT (System-wide Paediatric Observations Tracking) Programme was launched. 

A standardised paediatric early warning chart that records regular observations and highlights 
parameters for early escalation in acute hospital settings is currently being actively tested in 
several pilot Trust sites. There are future plans to extend an adapted framework of the acute 
charts to ambulance, NHS111 and primary care settings as part of a wider NHSE SPOT 
Programme led by the NHSE CYP Transformation Team. 

 
 
 
 
 
 
 
 The RCPCH hosts patient safety resources for its members and other health professionals via 
dedicated sections on the main RCPCH website and its focused microsite ‘QI Central’4, with 
quality improvement projects and open access educational resources in patient safety across a 
breadth of topics including clinical governance, situation awareness, patient-centred care, human 
factors and early detection of deterioration. A dedicated Patient Safety microsite and educational 
podcast series is currently in development for projected launch in 2023. 

We also signpost members to online learning resources to help paediatricians with ‘Spotting the 
Sick Child’. This contains over five hours of clinical footage of real patients, with learning pointers 
to help users focus on key themes. The user will learn how to assess seven common symptoms, 
which includes abdominal pain.  

111 algorithms  

It was useful to hear about the change to the 111 algorithms as a result of learning from the 
circumstances surrounding Esma’s passing. The pathways used to inform 111 are currently 
developed and managed by NHS Digital to the NHS in England and to individual users, including 
but not limited to NHS Pathways and 111online.nhs.uk. The RCPCH are not required to and do 
not endorse these pathways but paediatricians represent the RCPCH to provide clinical advice 
and expertise to inform their shaping and to provide clinical expertise on ad hoc queries and 
patient safety concerns.  

The RCPCH will take up further discussions with NHS Pathways to understand the changes 
made to these algorithms and to consider whether future work is needed to ensure all children 
who are deteriorating are referred to the appropriate acute paediatric health setting. The 
Academy of Medical Royal Colleges are in active discussion with NHS Digital about future 
arrangements for national clinical assurance of pathways that reflects the most up to date 
guidance and expertise. The RCPCH will be supporting the Academy by providing paediatric 
subject matter expertise to the clinical assurance workstreams.  

Separately, during the pandemic, the RCPCH supported the NHS 111 service by encouraging 
paediatricians who were shielding or not able to work in health settings for any reason to work in 
core NHS 111 centres to help manage the burden of high volume calls at that time. The NHS 
England CYP Transformation Team evaluated this pilot to understand feasibility of including 
paediatric expertise within NHS 111, and its impact on service delivery. The data showed that 
enhanced paediatric support within NHS 111 CAS is likely to reduce the large volume of children 
advised to attend ED or primary care, while improving the families’ experience.5  

Next steps 

Thank you for reminding us of the importance of this work. Your report will be shared further with 
our Quality in Clinical Practice committee for further discussion this Autumn, and any further 
opportunities that the RCPCH identify to ensure a death of this kind is prevented in the future will 
be established and taken forward at this committee.  

We will also continue to collaborate and support our colleagues at the Royal College of General 
Practice on promoting safe and effective pathways of care for children and young people. We are 
committed to carrying out the actions needed to ensure standards of care are maintained and the 

 
 
 
 
 
 
 
 
 
 child health workforce more broadly is represented in national discussions on children’s urgent 
and emergency healthcare, and patient safety.  

Yours sincerely, 

President 
Royal College of Paediatrics and Child Health