Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0339, written 15 Sep 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 15 Sep 2023 |
|---|---|
| Reference | 2023-0339 |
| Deceased | Riya Hirani |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Child Death (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: Prevention of Future Deaths report
Riya HIRANI (died 28.12.22)
THIS REPORT IS BEING SENT TO:
1. The Rt Hon Steve Barclay MP
Secretary of State for Health and Social Care
House of Commons
London SW1A 0AA
2.
National Medical Director
NHS England
Wellington House
133-135 Waterloo Road
London SE1 8UG
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 30 December 2022, one of my assistant coroners, Jonathan Stevens,
commenced an investigation into the death of Riya Hirani, aged 9 years.
The investigation concluded at the end of the inquest yesterday. I made
a narrative determination, a copy of which I attach.
Riya’s medical cause of death was:
1a hypoxic ischaemic encephalopathy
1b out of hospital cardiac arrest
1c invasive group A streptococcal infection and influenza B infection
1
4
CIRCUMSTANCES OF THE DEATH
Riya died in Great Ormond Street Hospital, having been transferred there
from Northwick Park Hospital in Harrow after she presented in cardiac
arrest on the evening of 23 December 2023. However, by that point
Riya’s condition was irretrievable, and she died five days later.
5
CORONER’S CONCERNS
During the course of the inquest, the evidence revealed matters giving
rise to concern. In my opinion, there is a risk that future deaths will occur
unless action is taken. In the circumstances, it is my statutory duty to
report to you.
The MATTERS OF CONCERN are as follows.
Riya’s mother took her to hospital a full day before Riya’s fatal collapse,
because she believed that Riya was very sick. Unfortunately, the junior
doctor who examined and assessed Riya failed to appreciate the severity
of her condition. Instead of giving her intravenous antibiotics and
admitting her to hospital, he diagnosed a virus and discharged her with
advice to take over the counter painkillers and a sheet describing the
management of sore throats.
I intend to make a PFD report to the medical director of Northwick Park
Hospital about the diagnosis and treatment of Riya’s condition.
However, I am writing to you both because it seems to me that there is a
fundamental issue regarding the lack of appropriate diagnosis and
treatment that is apparent locally but relevant nationally.
When Riya’s mother took her to hospital, she did so because it seemed
to her that this illness was qualitatively very different from any other that
Riya had suffered in her nine years. In short, Riya’s mum was convinced
that Riya was extremely ill, she articulated clearly and at every stage in
hospital why she thought that Riya was extremely ill, and she even
questioned the doctor about whether this could be a group A
streptococcal infection. (There was a well publicised outbreak at the time
and the hospital had actually received an alert about this.)
I heard at inquest that, even in the middle of the night, there was a
consultant available to give a second opinion if this had been requested
by medical personnel. However, no thought was given to seeking a
second opinion. I think it highly likely that if it had been open to Riya’s
family to seek a second opinion at that point, they would have done so
without hesitation.
One of the reasons that coroners are local to an area is because this
makes them better placed to recognise any local trends.
2
Although the events bringing the two children to hospital were very
different, as I listened to the evidence at Riya’s inquest I noticed some
striking similarities between the circumstances of Riya’s treatment and
those of Martha Mills. On each occasion a parent’s articulately
expressed and ultimately prescient concerns about a previously healthy
but rapidly deteriorating child, did not result in appropriate escalation of
care.
I heard the inquest touching Martha’s death last year. I am aware from
press reports of the attempts of Martha’s mother to enable families in
such a situation to have ready access to a second medical opinion. It
seems to me that you should be aware of the circumstances of Riya’s
death before you decide how to proceed.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that you have the power to take such action.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date
of this report, namely by 13 November 2023. I, the coroner, may extend
the period.
Your response must contain details of action taken or proposed to be
taken, setting out the timetable for action. Otherwise, you must explain
why no action is proposed.
8
COPIES and PUBLICATION
I have sent a copy of my report to the following.
•
•
•
• HHJ Thomas Teague QC, the Chief Coroner of England & Wales
, medical director, Northwick Park Hospital
, the parents of Martha Mills
, the parents of Riya Hirani
I am also under a duty to send a copy of your response to the Chief
Coroner and all interested persons who in my opinion should receive it.
I may also send a copy of your response to any other person who I
believe may find it useful or of interest.
The Chief Coroner may publish either or both in a complete or redacted
or summary form.
3
He may send a copy of this report to any person who he believes may
find it useful or of interest. You may make representations to me, the
coroner, at the time of your response, about the release or the publication
of your response.
9
DATE SIGNED BY SENIOR CORONER
15.09.23 ME Hassell
4
2 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Trust Management Office Northwick Park Hospital Watford Road Harrow HA1 3UJ Private and Confidential Senior Coroner (ME Hassell) Inner North London St Pancras Coroner’s Court Camley Street London N1C 4PP 17 November 2023 Dear Coroner, RE: Inquest of Riya Hirani 14 September 2023 We write further to the inquest touching upon the death of Riya Hirani, which took place on 14 September 2023. At the conclusion of this inquest, the Coroner issued a Prevention of Future Deaths (PFD) report. The PFD noted that the Coroner had concerns that the junior doctor did not appreciate the severity of Riya’s condition and in essence that incorrect medical treatment was provided. The PFD has been sent to the Trust, as the Coroner believes that the Trust has power to take actions to prevent further deaths. We have provided narrative on the actions already undertaken and future actions as detailed below. Point of care testing Point of care testing is now fully operational within our emergency pathway for measuring and assessing Streptococcus A and respiratory illness in children. New standard operating procedure A new locally devised standard operating procedure (SOP) entitled ‘Paediatric Medical Examination’ is in the development stage and this document details the escalation process for advice and support with clinical concerns both in and out of standard working hours for healthcare professionals when working with deteriorating children both in the emergency pathway and on the Paediatric inpatient wards. As part of this SOP, we are also introducing a SBAR model [which stands for Situation, Background, Assessment, Recommendation], this will help to create an understanding of a shared model around patient handovers and situations requiring escalation or critical Trust headquarters: Northwick Park Hospital, Watford Road, HA1 3UJ +44 (0)20 8864 3232 Find us online https://linktr.ee/lnwh_nhs exchange of information such as sepsis. This SOP also incorporates and supports the principles of Martha’s Law and the ability for families and health professionals to seek second and more senior opinions when remaining concerned after a clinical review. Additionally, the SOP now supports the need for discussion to the next level of seniority and a mandated Face-to-Face clinical review of all children seen within the emergency pathways prior to discharge. The SOP will be due for completion by the end of December 2023. This is currently in draft form and has been shared across speciality, with senior trust clinicians for input and socialisation. We would value input from Riya’s family into the finalised version of the SOP prior to formal ratification and would hope to co-produce the final document with them, but acknowledge this may understandably be difficult for them. Once finalised, the SOP will follow the Trusts governance process for formal ratification and will be shared widely with staff through local departmental, divisional and trust governance meetings. After ratification, the document will be available on the Trust intranet for ease of access and displayed in clinical environments. Our communications department will be approached to share on the trust bulletin and screen savers. As an interim measure pending completion of the SOP all clinicians have been advised through multi professional meetings and via email communication that if a caregiver raises concerns following clinical review the clinician should have a low threshold for seeking senior review. We would be happy to provide the coroner with an update and a copy of the ratified SOP once this has been completed. To provide assurance that this process has been embedded a clinical audit will be undertaken six months after its launch, and at annual intervals thereafter. Nationally approved Paediatric Early Warning System The Trust also confirms that the newly launched Nationally approved Paediatric Early Warning System observation and escalation charts, known as PEWS, will be implemented as per the national requirement. This tool is to support clinicians when assessing children who are acutely unwell or at risk or rapid deterioration and will enable staff to quickly be able to identify deterioration of the child, escalate care, and act on parental concerns. The PEWS charts have been collaboratively developed by clinical teams across England to standardise the approach of tracking the deterioration of children in hospital. Multi-disciplinary working In regard to the care of children with complex medical needs the Paediatric service has a weekly meeting where children with complex medical needs are discussed, and further guidance can be sought from other specialties where needed. The meeting is chaired by Trust headquarters: Northwick Park Hospital, Watford Road, HA1 3UJ +44 (0)20 8864 3232 Find us online https://linktr.ee/lnwh_nhs the Clinical Director of their designated deputy, and attended by the multi-disciplinary team and other clinical specialist disciplines when needed and a plan of care is agreed. The MDT includes a minimum of 6 paediatric consultants, junior doctors and nursing representation. In instances where a patient is acutely unwell and earlier input is required this occurs dynamically, rather than at the weekly meeting. Additionally, the Trust holds a monthly Deteriorating Patients Group. This is chaired by the Trust Medical Director and is an organisational Trust platform to discuss deteriorating patients, where cases are reviewed, and learning is embedded into future practices. This meeting is attended by Director level clinical staff from all clinical specialties and subgroups to ensure collaborative and robust oversight. This meeting is formally minuted, develops actions with named lead professionals and influences Trust policies and procedures. As a direct-action Paediatrics and the learning from any pertinent clinical presentations have been added as a standard agenda item. Clinical guidelines and National alerts are shared with staff through our governance, clinical and staff meetings and additionally electronically via email, and the Trust would like to reiterate that an audit of effective communication around clinical guidelines and national alerts will be undertaken. We hope that this satisfies the Coroner's concerns in this matter and if there is anything further that the Trust can aid with, please do let us know and we will be happy to address any further issues. Yours sincerely Chief Executive Officer Trust headquarters: Northwick Park Hospital, Watford Road, HA1 3UJ +44 (0)20 8864 3232 Find us online https://linktr.ee/lnwh_nhs
Trust Management Office Northwick Park Hospital Watford Road Harrow HA1 3UJ Private and Confidential Senior Coroner (ME Hassell) Inner North London St Pancras Coroner’s Court Camley Street London N1C 4PP 17 November 2023 Dear Coroner, RE: Inquest of Riya Hirani 14 September 2023 We write further to the inquest touching upon the death of Riya Hirani, which took place on 14 September 2023. At the conclusion of this inquest, the Coroner issued a Prevention of Future Deaths (PFD) report. The PFD noted that the Coroner had concerns that the junior doctor did not appreciate the severity of Riya’s condition and in essence that incorrect medical treatment was provided. The PFD has been sent to the Trust, as the Coroner believes that the Trust has power to take actions to prevent further deaths. We have provided narrative on the actions already undertaken and future actions as detailed below. Point of care testing Point of care testing is now fully operational within our emergency pathway for measuring and assessing Streptococcus A and respiratory illness in children. New standard operating procedure A new locally devised standard operating procedure (SOP) entitled ‘Paediatric Medical Examination’ is in the development stage and this document details the escalation process for advice and support with clinical concerns both in and out of standard working hours for healthcare professionals when working with deteriorating children both in the emergency pathway and on the Paediatric inpatient wards. As part of this SOP, we are also introducing a SBAR model [which stands for Situation, Background, Assessment, Recommendation], this will help to create an understanding of a shared model around patient handovers and situations requiring escalation or critical Trust headquarters: Northwick Park Hospital, Watford Road, HA1 3UJ +44 (0)20 8864 3232 Find us online https://linktr.ee/lnwh_nhs exchange of information such as sepsis. This SOP also incorporates and supports the principles of Martha’s Law and the ability for families and health professionals to seek second and more senior opinions when remaining concerned after a clinical review. Additionally, the SOP now supports the need for discussion to the next level of seniority and a mandated Face-to-Face clinical review of all children seen within the emergency pathways prior to discharge. The SOP will be due for completion by the end of December 2023. This is currently in draft form and has been shared across speciality, with senior trust clinicians for input and socialisation. We would value input from Riya’s family into the finalised version of the SOP prior to formal ratification and would hope to co-produce the final document with them, but acknowledge this may understandably be difficult for them. Once finalised, the SOP will follow the Trusts governance process for formal ratification and will be shared widely with staff through local departmental, divisional and trust governance meetings. After ratification, the document will be available on the Trust intranet for ease of access and displayed in clinical environments. Our communications department will be approached to share on the trust bulletin and screen savers. As an interim measure pending completion of the SOP all clinicians have been advised through multi professional meetings and via email communication that if a caregiver raises concerns following clinical review the clinician should have a low threshold for seeking senior review. We would be happy to provide the coroner with an update and a copy of the ratified SOP once this has been completed. To provide assurance that this process has been embedded a clinical audit will be undertaken six months after its launch, and at annual intervals thereafter. Nationally approved Paediatric Early Warning System The Trust also confirms that the newly launched Nationally approved Paediatric Early Warning System observation and escalation charts, known as PEWS, will be implemented as per the national requirement. This tool is to support clinicians when assessing children who are acutely unwell or at risk or rapid deterioration and will enable staff to quickly be able to identify deterioration of the child, escalate care, and act on parental concerns. The PEWS charts have been collaboratively developed by clinical teams across England to standardise the approach of tracking the deterioration of children in hospital. Multi-disciplinary working In regard to the care of children with complex medical needs the Paediatric service has a weekly meeting where children with complex medical needs are discussed, and further guidance can be sought from other specialties where needed. The meeting is chaired by Trust headquarters: Northwick Park Hospital, Watford Road, HA1 3UJ +44 (0)20 8864 3232 Find us online https://linktr.ee/lnwh_nhs the Clinical Director of their designated deputy, and attended by the multi-disciplinary team and other clinical specialist disciplines when needed and a plan of care is agreed. The MDT includes a minimum of 6 paediatric consultants, junior doctors and nursing representation. In instances where a patient is acutely unwell and earlier input is required this occurs dynamically, rather than at the weekly meeting. Additionally, the Trust holds a monthly Deteriorating Patients Group. This is chaired by the Trust Medical Director and is an organisational Trust platform to discuss deteriorating patients, where cases are reviewed, and learning is embedded into future practices. This meeting is attended by Director level clinical staff from all clinical specialties and subgroups to ensure collaborative and robust oversight. This meeting is formally minuted, develops actions with named lead professionals and influences Trust policies and procedures. As a direct-action Paediatrics and the learning from any pertinent clinical presentations have been added as a standard agenda item. Clinical guidelines and National alerts are shared with staff through our governance, clinical and staff meetings and additionally electronically via email, and the Trust would like to reiterate that an audit of effective communication around clinical guidelines and national alerts will be undertaken. We hope that this satisfies the Coroner's concerns in this matter and if there is anything further that the Trust can aid with, please do let us know and we will be happy to address any further issues. Yours sincerely Chief Executive Officer Trust headquarters: Northwick Park Hospital, Watford Road, HA1 3UJ +44 (0)20 8864 3232 Find us online https://linktr.ee/lnwh_nhs
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