Kyra Aslam

Western Bank 
Sheffield  
S10 2TH 

www.sheffieldchildrens.nhs.uk 

29 January 2024 

Dear Ms Combes,  

Kyra Aslam (Greaves)  
Regulation 28 

Further to the inquest of Kyra Ali Aslam which concluded on 6 July 2023.  I write in response to the 
Regulation 28 Report to prevent future deaths issued on 5 December 2023 to Sheffield Children’s 
NHS Foundation Trust. 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. 

Kyra sadly died on 13 August 2022 at Sheffield Children’s Hospital following a planned procedure 
to reverse a stoma.  

I  would  like  to  assure  you  that  the  Trust  takes  the  findings  and  the  concerns  very  seriously  and 
provides the following response to the concerns raised:  

1.  Whether there is a culture which prevents medics from taking account of the views 
of parents or nursing staff when considering the overall presentation of patients. 

The Trust has recognised that the views of parents and nursing staff have not always been 
listened  to,  through  feedback  we  triangulate  from  inquests,  serious  incidents  and 
complaints. As a result of this, we have undertaken a significant amount of work to consider 
and improve areas within our culture and the processes that underpin our ways of working.  
This includes:  

• 

• 

Implementing new processes to ensure the clinical Care Groups are fully sighted on 
all complaints and Freedom to Speak Up themes including ones where families or 
colleagues feel unheard so that they can discuss and learn from these within their 
internal forums. 
Implementation of ‘Safety Wednesday’ led by the Medical Director and Chief Nurse 
to  review  all  incidents  and  complaints  through  the  week.    Areas  of  concern  are 
escalated to Patient Safety Incident Triage Panel for further consideration and fed 
into  the  weekly  Executive  Team  meeting  on  a  Thursday  to  enable  timely  action.  

               
 
 
                                                                                                              
                 
         
 
 
 
 
  
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The learning from this process has already been rich and has specifically enabled 
me as Chief Executive (CEO) to speak to families before discharge, if appropriate.  
•  A new monthly Safety, Quality, Risk and Learning Committee provides a forum for 

organisation wide learning. 

•  Funding  new  Trust  wide  roles  including  Quality  Matron;  Patient  Experience  Leads 

and a sepsis Lead Nurse. 

•  Refresh of our Care Experience Group including stronger attendance, feedback and 

• 

coproduction of action from The Trust’s Youth Forum and Healthwatch.  
Implementing  the  new  national  Patient  Safety  Incident  Response  Framework  with 
significant training and appointment of new Learning Response Learning Leads.  

•  Roll out of human factors training across the Trust. 
•  Thorough  review  of  bereavement  care  following  themes  identified  from  incidents 
and complaints with input from families and the development of future proposals. 
•  Embedding the Trusts ‘In it Together’ culture framework within our People Plan and 

supporting this with leadership events and line management training. 

•  Scheduled  Consultant  engagement  meetings  for  2024,  where  feedback  from 

specific learning can be shared with the Consultant body in the Trust.  

•  Development  of  the  Team  Leader  role  for  doctors  with  a  refreshed  job  role  and 

• 

review of time allocated for the role.  
Invitation of external groups to talk to Executive Team and Trust Board for example 
the Sheffield parent / carer forum came to present feedback from their engagement 
work  Implementation of Patient and Carer Escalation  

.  
Parent and Carer Escalation (PaCE) 

The  Trust  has  implemented  a  new  process  to  enable  parents  and  carers  to  escalate 
concerns about their child’s clinical condition if they feel they are not being listened to. This 
new process is called PaCE (Parent and Carer Escalation). It is acknowledged by Sheffield 
Children’s  NHS  FT  that  failure  to  recognise  and  treat  patients  whose  condition  is 
deteriorating is a cause of significant harm in healthcare environments. One resource in the 
early detection of deterioration is the contribution that patients and carers can make.  

Understanding  parental  concern  as  an  indicator  of  clinical  deterioration  and  empowering 
them to speak up when they are worried is key in the context of improving care quality and 
safety  particularly  in  terms  of  preventing  avoidable  harm  in  children.  PaCE  is  a  four-step 
process to encourage the concerned parent/ carer to initially speak with the nurse or doctor. 
If  they  are  still  worried  they  ask  for  the  nurse  in  charge  of  the  ward.  If  concerns  continue 
they  can  ask  to  speak  to  the  ward  manager  or  the  site  manager  and  if  they  are  still 
concerned  following  all  these  conversations  they  can  call  the  number  displayed  on  the 
poster to speak to the Senior Nurse on Call. 

Posters  are  prominent  in  all  inpatient  areas.  The  new  process  was  initially  trialled  on  two 
wards.  Following  successful  pilots  this  has  been  rolled  out  to  all  in-patient  areas  on  the 
hospital site across the Trust from 3 November 2023.  To date one call has been made to 
the  Senior  Nurse  on  Call  and  we  will  continue  to  promote  and  monitor  use  to  ensure  all 
patients  and  carers  feel  able  to  use  this  if  needed.    Further  work  we  want  to  develop  is 
around  cultural  competency  of  colleagues  and  ensuring  any  processes  we  have  are 
inclusive and accessible.  

The Trust has processes and policies in place for escalation by nurses should they feel that 
their concerns are not being heard, these policies are being updated and will be supported 
by training. The new Quality Matron post will play a significant part in enabling this culture 
change at ward level. All clinical colleagues also have access to the Freedom to Speak Up 
Guardian who will take concerns and raise these directly with the Executive Team.  

               
 
 
                                                                                                              
                 
         
 
 
 
 
 
 
 
  
  
 The  Trust  is  committed to  developing  our  leaders  and  teams so  that  everyone feels  safe, 
are  able  to  team  up  and  to  keep  learning.  Our  Lead  with  Care  framework  supports  this 
cultural  approach  and  is  something  I  personally  champion  as  CEO.    We  have  been  very 
open within the Trust about our need to increase listening to our families and why we have 
put  actions  in  place.  As  CEO  I  have  reported  back  to  our  Trust  Board  on  themes  we  are 
hearing  and  the  actions  in  place.    Whilst  we  have  some  areas  of  outstanding  practice 
already,  we  are  determined  in  our  aim  to  have  consistency  across  the  Trust.    We  will  be 
working hard to embed these actions to create the culture change everywhere for the safety 
and experience of all patients and families.  

2.  Where  a  junior  doctor  is  overruled  by  a  Consultant,  is  that  learning  adequately 

explained to that junior doctor to learn for next time? 

We believe that Sheffield Children’s is a positive learning environment and this is evidenced 
in many areas by the GMC national trainee survey and by positive HEE quality assurance 
visits.  We  have  however  submitted  an  educational  action  plan  to  HEE  to  address  areas 
where  training  is  not  at  the  level  we  expect,  and  our  Director  of  Postgraduate  Medical 
Education continues to review the quality and develop learning across all posts.  

We  have  invested  in  additional  time  for  speciality  clinical  tutor  posts  which  support  the 
development  of  education  locally  for  doctors  in  training  and  act  as  a  local  support  for 
trainees  to  discuss  their  training  and  training  needs.  Any  trainee  placed  at  Sheffield 
Children’s  has  a  personal  clinical  supervisor  assigned  to  them,  their  role  is  to  provide 
learning  through  case-based  discussions  and  review  of  their  experiences  (and  address 
unmet learning needs or concerns).  

As a Trust we have introduced a new way for consultants to evidence their upskilling as a 
Clinical  and  Educational  Supervisor.  This  is  now  linked  to  their  appraisal  process  within 
their Scope of Work and gives very clear suggestions on how to meet the seven domains 
required  by  the  GMC.  We  believe  that  this  will  maintain  high  standards  amongst  our 
trainers,  increase  their  accountability  and  ensure  they  receive  regular  training  to  improve 
their approach to teaching and give them confidence to challenge colleagues who are not 
meeting the same standards. Acute medicine can at times require fast decision making by 
the  most  senior  colleague  present  which  can  be  appropriate  in  emergency  situations, 
however  embedding  improved  supervision  training  for  all  supervisors  will  work  towards 
ensuring that all clinical contacts are viewed as learning opportunities.  

Additionally, trainees have access to the Freedom to Speak Up Guardian and the Guardian 
of  Safe  Working.  Trainees  are  signposted  to  them  as  part  of  the  induction  process.  The 
confidentiality  of  those  speaking  up  is  respected,  in  line  with  the  Freedom  to  Speak  Up 
the  Executive  Medical 
Principles. 
Director/Deputy  Medical  Director  who  review  the  issues  raised  and  if  appropriate  discuss 
with  the  individual(s).  We  also  have  a  very  active  junior  doctor  forum  which  encourages 
trainees to share concerns that they have about training posts within the Trust. 

Issues  raised  are  brought 

the  attention  of 

to 

The continued work we are doing with our Quality Strategy, known as the Quality Promise, which 
has just been launched across the Trust, will assist in embedding our culture to provide safe, kind 
and outstanding care to everyone.  In implementing human factors, engagement with leaders and 
everyone  across  the  Trust  highlighting  the  importance  of  listening  to  parents/  carers  and  other 
colleagues  across  the  Trust,  along  with  the  learning  culture  that  is  being  implemented  through 
PSIRF (Patient Safety Incident Response Framework).  

               
 
 
                                                                                                              
                 
         
 
 
 
 
 
 
 
 
 
 
 
 
 The Trust’s ‘In this Together’ culture and behaviour framework, Lead with Care approach and the 
Education  and  Learning  Strategy  that  have  been  rolled  out  across  the  Trust  will  ensure  that  our 
culture develops and that learning is embedded across all areas including surgery.  

As  the  CEO  of  Sheffield  Children’s  the  culture  of  our  Trust  is  of  huge  importance  to  me.  I  have 
personally triangulated and fed back themes that have been raised and identified to our Board and 
I am ensuring that we continue to develop and embed our culture through further projects including 
our bereavement care and sepsis work.  

I trust that this provides adequate assurance on the matters of concern. Please do not hesitate to 
contact me if you require anything further. 

Yours Sincerely,  

Chief Executive