Shahan Aman

Trust Executive Office  
Ground Floor  
Pathology and Pharmacy Building  
The Royal London Hospital  
80 Newark Street  
London E1 2ES  
Telephone: 020 32460641  

www.bartshealth.nhs.uk 

Date: November 11, 2022 

Private & Confidential 
Mr Graeme Irvine 
Senior Coroner 
Walthamstow Coroners Court  
The Adult College of Barking & 
Dagenham 
127 Ripple Rd 
Barking 
IG11 7PB 

Dear Mr Irvine 

RE: Regulation 28 Prevention of Future Deaths Report 

I write in response to your Regulation 28 Report to Prevent Future Deaths, dated 30th September 2022 
touching on the death of Shahan Abu Aman. 

I can assure you that, prior to the receipt of your report, the Trust recognised the severity of the concerns 
raised by this sad case and has undertaken a large amount of work to ensure that the chance of recurrence 
is reduced to a minimum. We believe that our response will hopefully provide a level of reassurance to 
address the matters of concern outlined in your report. 

While acknowledging the seriousness of the highlighted concerns, it is important to note that this incident 
occurred on the background of a department that saw 150,487 patients; of which 37,146 were children in 
the year 2021. We do not believe that there is an inherent systemic process failure; however, we have 
introduced controls as outlined below which are designed to minimise the risk of recurrence of this tragic 
outcome.    

This Paediatric Emergency Department provides 24 hour per day cover and serves a diverse community.  
It is staffed by medical and nursing staff of various grades, and it has systems in place that ensure safe 
triage and disposition.  To support the final disposition of patients we have an in-patient ward, a paediatric 
assessment unit, our co located GP run urgent treatment centre, as well as a resuscitation room.   

 
 
 
         
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 Matters of Concern. 
A series of miscommunications between, nursing staff, junior and consultant paediatric medical 
staff resulted in concerns regarding Aman not being properly considered prior to discharge.   
Staff relied on assumptions that others understood the factors affecting Aman and had a plan to 
resolve them, this was not the case.  Had effective communication occurred it was unlikely than 
Aman would have been discharged.  

In this particular case, which we believe to be an isolated incident, there was a communication failure as 
identified as a matter of concern .  It is extremely difficult with any communication failures to pinpoint an 
exact cause.  However, despite this being said, the department did recognise the failure of this important 
element that did translate into the erroneous discharge decision.   

With any tool that is used to quantify risk, such as an early warning score, there is always the possibility 
that  it  will  never  be  100%  sensitive.    The  department  has  recognised  that  in  patients  presenting  with 
gastroenteritis, despite them being critically unwell, the early warning score system may not recognise this 
and lends itself to aligning itself with a false sense of reassurance.  In this case the individuals concerned 
recognised the patient was unwell but there was a communication failure where the weight of their concern 
was not able to be translated and transmitted for everyone to be aware.    

The Paediatric Emergency Department has now implemented and is using a detailed 2 hourly SITREP 
(Situational  Report).  The  SITREP  aims  to  capture  this  exact  concern  from  members  of  staff  who  are 
worried  about  a  patient  who,  despite  the  psychological  parameters  being  abnormal,  the  early  warning 
score does not identify this concern.    

The Paediatric SITREP report addresses this element of concern as evidenced below.  

The above tool is an objective measure that provides a trigger for staff to identify, document and escalate 
the concern.  The tool is run on a 2 hourly basis every day.    

The  severity  of  this  case  was  also  personally  discussed  and  fed  back  by  the  Clinical  Director  of  the 
Emergency Department and by the Consultant in Paediatric Emergency Department at various forums.  
Within these forums the importance of communication was strenuously emphasised.   

The theme of communication failures was furthermore specifically discussed with all the senior paediatric 
nursing staff by the Clinical Director on 15th July 2022 with an attendance register which has already been 
evidenced.  We would like to emphasise that the nursing staff who were involved in this case, were also 
present and shared their involvement and learning with this case.    

Over and above what has been mentioned, the theme of communication failure was not just aimed at the 
Paediatric Nursing team but is one that the Clinical Director himself personally emphasises; and has done 
so for at least 7 years at the Junior doctor’s induction programme.  The department feels confident that its 
messaging regarding the risks of communication failure are constantly reinforced.    

Communication  failures  alone  were  recognised  as  not  being  the  sole  contributor  as  clinical  knowledge 
regarding diarrhoea and vomiting in children and the risks of its dangers being under-appreciated were 

MRNCurrent PEWSWhat is the concern?Escalated to senior?0MRN for patients with PEWS  ≤6 AND nursing or medical concernsPlan?Patients triggering PEWS ≤6 BUT nursing/medical concerns should be recorded here and escalation plan noted.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 also  acknowledged.    With  this  in  mind,  the  evidence  bundle  which  has  already  been  provided, 
demonstrates all the teaching and educational efforts that we have put in place and continue to provide; 
highlighting  the  importance  of  this  case.  Within  these  teaching  modalities,  although  not  explicitly 
mentioned, the emphasis on communicating concerns remains a rolling theme.    

This  case  and  its  investigation  have  also  fed  into  the  Trust’s  robust  clinical  governance  process  that 
emphasises learning from incidents and a just culture. This as well as all serious incident investigations 
conclude  with  actions  to  ensure  final  reports  are  shared  with  relevant  clinical  staff  for  their  reflective 
learning.  Learning  summaries  are  also  completed  for  all  investigations  and  this  is  shared  across  all 
hospitals within the Trust for learning. These steps have all taken place with respect to this case.    

Serious  incidents  relating  to  specific  themes  are  also  discussed  for  learning  as  appropriate  through 
relevant  governance  arrangements.  For  example,  incidents  of  failure  to  rescue  are  considered  at  the 
hospital deteriorating patient improvement group, as well as other groups such as pressure ulcer incidents 
reviewed  at  the  hospital  pressure  ulcer  improvement  steering  group  and  falls  related  incidents  at  the 
hospital falls improvement group.  

Specific  sharing  of  lessons  learned  from  incidents,  as  was  in  this  case,  also  occur  through  speciality 
governance  meetings,  through  to  divisional  governance  meetings  and  the  hospital  quality  and  safety 
board. 

Furthermore, the implementation of actions resulting from “recommendations for action” following serious 
incident investigations have oversight through the divisional governance boards, and the hospital quality 
performance reviews. In this particular case, the actions have been completed and evidenced.    

The  doctor  who  authorised  discharge  did  not  satisfy  himself  of  the  most  recent  set  of  clinical 
observations and associated Paediatric Early Warning Sign (PEWS) score prior to discharge.  

This is a theme that was recognised before the inquest. In response, processes were put in place whereby 
the last set of observations and blood results over which a clinician makes an entry into the records, are 
auto-populated so that the clinician can be sighted on these.  In this particular case the early warning score 
identified  only  1  abnormal  parameter  which,  according  to  National  Guidance,  does  not  merit  repeated 
frequent observations. However, as mentioned above the department fully recognises that no system can 
be 100% sensitive and has put in a large amount of effort to ensure that the messaging/learning is shared 
that children presenting with gastroenteritis, despite low early warning scores, can be critically unwell.  This 
educational programme has already been demonstrated in the evidence provided to the court.   

The clinician in this particular case recognised that he did not satisfy himself with the most recent set of 
clinical observations that were undertaken but not translated to him. The clinician has undertaken a large 
amount of self-reflection where he has demonstrated insightfulness with respect to his involvement in the 
case and demonstrated how he has educated himself; thus, minimising the likelihood of a reoccurrence 
again.    

The Paediatric Emergency Department was particularly busy that evening, with a combination of 
high patient numbers and severe acuity of symptoms.  The accounts provided by Trust witnesses 
was that resulted in a pressurised environment and that this was a situation that occurred with an 
increasing level of frequency over the last two years.  

The Paediatric Emergency Department on a 24 hour basis is supported by consultants and registrars who 
are at the level of ST4 and above. In this particular case the Emergency Department doctor was one who 
had already taken a period of training in paediatrics and was one who was working at the level of ST4 i.e. 
that of a senior decision maker. This case unfortunately highlights the reality that clinical judgements can 
be difficult even in relatively experienced and expert hands.     

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 On this particular day the department was extremely busy and it is not always possible, as is the case in 
all Emergency Department, that every shift would be 100% fully staffed with no need for locums or the 
movement of staff from one area to another.  

The organisation has recognised a number of areas of pressure in the emergency departments and is in 
the  process  of  working  through  process  pathway  redesign  so  that  we  can  potentially  reduce  the 
pressurised working environment and reduce levels of risk.    

Outside the Emergency Department the Trust has plans to work alongside North East London to support 
paediatric flow, from the Emergency Department. This includes, but is not limited to, exploring ambulatory 
step  down  from  the  paediatric  ward,  increased  use  of  paediatric  clinical  decision  unit  to  work  into  the 
community to support early discharge.  In addition to working alongside the complex discharge team, we 
are exploring additional roles to support children on the ward who find themselves stranded to an array of 
complex conditions. This is all monitored through the divisions, support and assurance meetings up to and 
including the Executive boards.  

Thank you for bringing your concerns to my attention.  I am very happy to discuss or clarify any of the above 
points.  

Yours sincerely 

Chief Medical Officer

• 

Department 
of Health & 
Social Care 

Mr Graeme Irvine 
HM  Senior Coroner 
Walthamstow Coroner's Court 
Queen's Road Walthamstow 
E17 8QP 

Dear Mr Irvine, 

From Will Quince 
Minister for Health and Secondary Care 
39 Victoria  Street 
London 
SW1H0EU

16th  June 2023 

Thank you for your letter of 30 September 2022, to the then Secretary of State for Health and 
Social Care, Therese Coffey,  about the death of Shahan Aman .  I am replying as Minister with 
responsibility for Health and Secondary Care. 

Firstly,  I would like to s-ay how deeply saddened I was to read of the circumstances of Shahan's 
death.  I can appreciate how distressing his death must be for his parents and those who knew 
and  loved  Shahan  and  I offer my heartfelt condolences.  It  is  vital that we take the learnings 
from what happened to him  in  order to prevent future deaths. 

In preparing this response,  Departmental officials have made enquiries with NHS England and 
the Care Quality Commission  (CQC) . 

I  have  been  informed  by  my  officials  that  several  actions  have  been  taken  by  Barts  Health 
Trust following  Shahan's  death,  including  updated  guidance  on  managing  gastroenteritis  in 
children  as part of an  awareness campaign for Emergency Department staff and  revising the 
Emergency Department's policy on  observations prior to  discharge.  Emergency Department 
clinicians  are  also  being  prompted to consider adding  the  assessment of urine output as  an 
option  to  the  online  patient  documentation  system  for  Emergency  Department  clerking . 
Outcomes of this  investigation will  be shared with  the  patient's next of kin  and  staff involved  . 
directly  in  the  patient's  care  for their  reflective  learning.  More  broadly,  learning  summaries 
from the serious incident will  be  shared for trust-wide learning. 

The  Government  recognises  the  pressures  the  service  is  facing  - and  it  is  taking  a  whole-
system approach to ensure people get the emergency care they need when they need  it. 

Our Delivery  Plan for Recovering  Urgent and  Emergency Care  Services  aims to  deliver one 
of the fastest and  longest sustained  improvements  in  emergency waiting  times  in  the  NHS's 
history,  including  bringing  down  A&E  wait  times  significantly  over the  next  year,  and  down 
towards pre-pandemic levels within two years. 

To  increase  capacity  and  reduce  waits,  the  plan  will  deliver 5,000  more  staffed,  permanent 
beds this year compared to 2022/23 plans, alongside 800 new ambulances including specialty 
mental  health vehicles.  This is backed by £1  billion  of dedicated funding. 

We  will  also  make  greater  use  of  'virtual  wards',  with  an  extra  3,000  virtual  ward  beds  to 
provide  over  10,000  in  total  by  this  autumn,  allowing  patients  to  be  safely  monitored  and 
supported  towards  recovery from  the  comfort  of their own  home.  Longer term,  we  will  build 
capacity to allow staff to care for up to 50,000 patients a month this way. 

 
 
 Same  Day  Emergency Care services will  also  be  in  place  across every hospital with  a major 
emergency department, helping avoid  unnecessary overnight stays in  hospital. 

We  are  expanding  and  better joining  up  health  and  care  outside  hospital  helping  to  reduce 
admissions  to  A&E,  including  scaling  urgent  community  response,  frailty  and  falls  services 
across the whole country. 

The  plan  will  also  grow the  NHS111  clinical  workforce, make  urgent  mental  health  support 
universally  available  in  111  services,  and  expand  and  promote  NHS111  online  to  ensure 
patients can  access the right care first time,  and  only visit A&E when  necessary. 

We  are  also  investing  £1.6  billion  over  the  next  2  years  to  reduce  the  numbers  of  beds 
occupied  by  patients ready to  be  discharged. This  includes  establishing  'Care transfer hubs' 
in  every hospital ahead of next winter,  alongside new approaches to step-down  care. 

I hope this  response is  helpful  and thank you for bringing these concerns to  my  attention. 

Yours sincerely, 

WILL QUINCE  MP 
MINISTER OF  STATE FOR HEALTH