Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0376, written 10 May 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 May 2023 |
|---|---|
| Reference | 2023-0376 |
| Deceased | James Philliskirk |
| Coroner | Abigail Combes |
| Coroner area | South Yorkshire (Western) |
| Category | Child Death (from 2015) · Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Sheffield Children's NHS Foundation Trust 1 CORONER I am Abigail Combes, assistant coroner, for the coroner area of South Yorkshire (West District) 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 13 October 2022 I commenced an investigation into the death of James Philliskirk born on 11 January 2021. The investigation concluded at the end of the inquest on 24 April 2023. The conclusion of the inquest was:- James was referred to hospital on 12 May 2022. Following a number of assessments in hospital, James was misdiagnosed and was not provided with treatment in line with departmental guidance. He developed sepsis and died at home on 13 May 2022. His death was contributed to by neglect. The medical cause of death was: 1a: Sepsis 1b: Group A streptococcus skin infection 4 CIRCUMSTANCES OF THE DEATH James had had chicken pox and recovered in April 2022. He returned to nursery and on 10 May 2022 nursery reported that James was more clingy than normal and seemed like he may be unwell. His parents monitored him and determined on 12 May 2022 that they would seek medical support. They saw the family GP who reviewed James, heard that there may have been exposure to Scarlett Fever at nursery and heard him make a groaning noise which concerned him so he sent James into Sheffield Children's Hospital A&E with his father. James was seen by a triage nurse and a clinical fellow and a diagnosis of chicken pox was made. James had a lesion on his right wrist which ought to have been looked at more closely and the fact that he had recently had and recovered from chicken pox ought to have generated a senior review of his condition. James was sent home. James' mother returned from work and felt that he was more unwell. As a result she sought support from 111 who spent some time speaking to James' mother and heard James groaning. They asked James' parents to take him into A&E within the hour but 1 the sooner the better for further assessment. James returned to A&E with his mother and was reviewed by the same triage nurse. He was reviewed by a junior doctor who formed the view that the first episode of chicken pox must be a mis-diagnosis and he persisted with a diagnosis of chicken pox. Again, the fact that James had been brought back into A&E so soon and the suggestion of a reinfection with chicken pox should have generated a senior clinical review but it did not. James was sent home and continued to be unwell that evening. His mother and father determined they would return the following day however James died at home in the night. A post mortem revealed that he had developed sepsis. I heard evidence from the Hospital that had James been sent into A&E through the usual GP referral route then he would have been triaged and seen in the medical unit which would have greater level of senior oversight, a different set of more detailed guidance for re infection with chicken pox and would have stayed for longer making it more likely that the groaning would have been heard. All of this would make it more likely that James would have lived. There were however significant opportunities for James' condition to be identified in A&E notwithstanding this process change. It was also apparent in evidence that James should have had senior escalation and the lesion on his wrist should have been identified as being different from a normal presentation of chicken pox. A&E hold a handbook which provides advice and guidance on a vast array of conditions which may be seen in A&E. This is inevitably not as detailed as the medical guidance issued to specialties at the hospital. Crucial sections of the specialist guidance were not easily identifiable in the A&E handbook including the need to seek senior advice in certain circumstances or identify the risks from recent reinfection of chicken pox. This guidance therefore was not able to influence decision making of clinicians looking after James in hospital. 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 could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – 1. Junior staff not knowing when to escalate concerns 2. Unclear guidance in the handbook relating to chicken pox and reinfection and the need for aggressive antibiotic treatment if reinfection occurs soon after the initial infection 3. Confirmation bias affecting clinical reviews 4. Lack of proper assessment of existing skin lesions in chicken pox even where identified by parents 5. Lack of knowledge of the risk of secondary complications from recent chicken 6. pox infection in the emergency department Insufficient weight on GP referral when not through the identified route of referral (ie presentation straight to A&E which amounts to 25% of referrals). I heard evidence that an IT system is in development to resolve this however engagement of NHS Digital and the Commissioners is required to progress. For the avoidance of doubt, had the GP referral been processed in the usual way James would have gone through to the medical unit and the result would have been senior oversight and a strong likelihood that James would have received IV antibiotics and survived. 2 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation 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 5 July 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 Chief Coroner and to the following Interested Persons: and Sheffield Children's NHS Foundation Trust. 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. In this case I have sent a copy of this report to NHS England, NHS Digital and to NHS South Yorkshire ICB. The Chief Coroner may publish either or both in a complete or redacted or summary form. 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 10 May 2023 ABIGAIL COMBES 3
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.
L Western Bank Shef f ield S10 2TH www.shef fieldchildrens.nhs.uk 30 June 2023 Dear Ms Combes, James Edward Philliskirk (deceased) Regulation 28 I write in response to your Regulation 28 Report to Prevent Future Deaths dated 10 May 2023. Under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 you requested the Trust to consider your matters for concern and take action to prevent future deaths. The Matters of Concern and the Trust’s responses are as follows: 1. Junior staff not knowing when to escalate concerns. In order to address this concern, improvements to the induction training for junior doctors have been made. These improvements have included providing information on when junior staff should escalate concerns to senior staff. The guidelines relating to reattenders, fever, chicken pox and sepsis are brought to the attention of the junior doctors so that they are clear on when it would be appropriate to escalate. In addition, junior doctors receive regular WhatsApp messages and emails alerting them to any prevalent illness and the relevant training and information they need to access at that time. Work is also ongoing to increase senior leadership within the Emergency Department (ED) at the Trust by implementing a new Specialty Doctor rota and increasing the consultant hours within ED. A Trust job advertisement closes today for 2 Speciality Doctors and the Medicine Care group have applied for funding to add an extra Consultant shift every weekend, with locum shifts to be offered by October in the event that funding has not been secured. With an increased presence of senior decision makers, there will be greater supervision of junior doctors, more senior staff to review re-attenders alongside sicker children and an increased capacity for training and audit. In addition, the Trust’s IT department is working on adding a reattender flag onto the electronic medical records system, which would alert the senior clinicians to the fact that a reattender was in the department. It is anticipated that this will be in place by the end of July 2023. Chief Executive Chair 2. Unclear guidance in the handbook relating to chicken pox and reinfection and the need for aggressive antibiotic treatment if reinfection occurs soon after the initial infection. As provided in evidence during this inquest, the guideline relating to chicken pox was amended in response to immediate learning and a copy of this was sent to you on 2 May 2023. Subsequently more work is being undertaken to develop the guidelines further with the Emergency Department clinicians, Infectious disease specialists and the Paediatricians. This work will be completed by the end of September 2023. 3. Confirmation bias affecting clinical reviews. The induction training for junior doctors now includes a module called ‘Keeping Safe in ED’. In August 2022 this was added to the induction to discuss human factor principles (including confirmation bias) and the importance of listening to parents. In addition, throughout the Trust, work is being done to raise awareness of human factors, their role in decision making and how errors can occur. Funding has been acquired to make educational videos highlighting this vitally important area. They will be used to support the education of all staff groups now and future cohorts across the Trust as well as in the ED. 4. Lack of proper assessment of existing skin lesions in chicken pox even where identified by parents. The amended Chicken Pox Guideline is now clearer on how secondary bacterial infections can present. The new Induction module “Keeping Safe in ED” covers key learning from this case about chicken pox as well as the importance of listening to parents. Human factor training planned as part of the educational video will cover areas like heuristic thinking and confirmation bias which were factors in this case. Raising awareness to staff of these factors in decision making will help future decision making in the highly pressurised environment of ED. Prior to induction, ED junior doctors receive a pack which includes a chapter on paediatric rashes including chicken pox. Four hours of training time is given to ED junior doctors each week and they are encouraged to cover this pre-induction pack in their first few weeks if not covered prior to starting, to ensure they have appropriate knowledge of rashes and risks of secondary complications. This will ensure that they assess rashes effectively in the ED. Work is in progress to increase ED senior staffing to allow enhanced supervision of juniors assessing patients including those with rashes and support further education. 5. Lack of knowledge of the risk of secondary complications from recent chicken pox infection in the emergency department. The risk of secondary complications from recent chicken pox infection is included in the Trust Guideline relating to chicken pox. As provided in evidence during this inquest and also in response to point 2 above, the guideline relating to chicken pox has been amended and a copy of this was sent to you on 2 May 2023. The amended guideline is clearer on how complications present clinically. Further work is being undertaken to develop the guidelines with the Emergency Department clinicians , Infectious disease specialists and the Paediatricians and this work will be completed by the end of September 2023. Chief Executive Chair A new Chicken Pox Patient Information Leaflet has been drafted and sent to be processed on the patient resource library. Knowledge of important complications in any febrile child including chicken pox is covered in ED Induction and specifically in the new “Keeping Safe in ED” session. Increasing the ED Senior workforce is a top priority for the department and Trust to enable enhanced teaching, training and supervision both clinically and non-clinically. Recruitment is in progress, with the aim to have the first phase of increased staffing by October 2023. 6. Insufficient weight on GP referral when not through the identified route of referral (i.e. presentation straight to A&E which amounts to 25% of referrals). As confirmed in evidence at the inquest, a reminder has been sent via the Integrated Care Board communications team to primary care, reminding them of the current referral system, so that the correct referral pathway is used, including a reminder to provide a copy of a new leaflet to parents explaining the system in place and the need to attend AAU (The Acute Assessment Unit). As a safety net, any patient arriving with a letter from the GP but who has not been formally referred through the correct pathway, will be seen by the appropriate team as they would, had the correct referral pathway been followed. If a patient has been seen in primary care and not formally referred and it is unclear which team at the Trust should see the child, an ED Consultant will review the letter to ensure they are seen by the appropriate team. Our clinical management team will be working with our primary care colleagues towards a more permanent solution for the referral aspect of the patient pathway. At this time, we are unable to confirm whether this will require a digital solution such as an electronic referral system but have oversight from our digital colleagues to ensure that if such a solution is required it can be practically implemented. I trust that this provides adequate assurance on the matters of concern. Please do not hesitate to contact myself if you require anything further. Yours Sincerely, Chief Executive Chief Executive Chair
L Western Bank Shef f ield S10 2TH www.shef fieldchildrens.nhs.uk 30 June 2023 Dear Ms Combes, James Edward Philliskirk (deceased) Regulation 28 Please find enclosed Sheffield Children’s NHS Foundation Trust’s formal response to your Regulation 28 Report to Prevent Future Deaths dated 10 May 2023. Under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 you requested the Trust to consider your matters for concern and take action to prevent future deaths. on 12th June 2023. I took As Chief Executive of the Trust, I met with this opportunity to say how very sorry I am to James and everyone who loved him, that Sheffield Children’s Hospital contributed to James’s death by neglect. I am sorry that we misdiagnosed him and that he wasn’t provided the right treatment whilst in our care. I feel regretful that we did not meet sooner and whilst it felt important to apologise in person, I also regret that we were not in touch with the family straight after the inquest to offer our apologies. This is something I have ensured we change straight away. The outcome of the inquest and matters for concern for preventing future deaths, our serious incident actions and wider review of areas for improvement, all ensure we will learn and take action. However, hearing James’s story directly from his parents, and their lived experience over the last year, brought into stark focus the areas we must learn from at Sheffield Children’s Hospital. I took immediate personal action to ensure I was fully appraised and assured of the actions we had in place and continued to take. We also accepted generous offer to speak to our Trust Board and she joined us on Tuesday 27th June. The impact of our whole Board of Directors hearing James’s story directly from was palpable. It was a poignant moment in our Trust history that will be remembered by us all and will inform how we seek assurance in the future. I have arranged to provide a full update to in July and this will be followed up with a meeting on 13th July 2023. I trust that this letter and the enclosed Trust’s Regulation 28 Response provides adequate assurance on the matters of concern. Chief Executive Chair Please do not hesitate to contact myself if you require anything further. Yours Sincerely, Chief Executive Chief Executive Chair
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