Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0023, written 12 Jan 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 Jan 2024 |
|---|---|
| Reference | 2024-0023 |
| Deceased | Iona Buckingham |
| Coroner | Jonathan Dixey |
| Coroner area | Northamptonshire |
| Category | Child Death (from 2015) · Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Kettering General Hospital NHS Foundation Trust · Northampton General Hospital NHS Trust · University Hospitals of Leicester NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: (1) NORTHAMPTON GENERAL HOSPITAL NHS TRUST (2) NHS NORTHAMPTONSHIRE INTEGRATED CARE BOARD (3) NHS ENGLAND 1 CORONER I am Jonathan Dixey, assistant coroner, for the coroner area of Northamptonshire. 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 14th December 2022 an investigation was commenced into the death of Iona Grace Buckingham, aged 9 months. The investigation concluded at the end of the inquest on 10th January 2024. The conclusion of the inquest was a narrative conclusion: there was a missed opportunity Iona Buckingham died as a result of bronchopneumonia with empyema due to invasive Group A streptococcal infection. On 29 November 2022 clindamycin, an antibiotic, which possibly contributed to Iona’s death. On 3 December 2022 there was a further missed opportunity to (i) undertake an x-ray; (ii) administer clindamycin; and (iii) arrange for transfer to a tertiary centre for the purpose of undertaking a chest drain. These matters probably contributed to Iona’s death. Iona died during an accidental extubation on 4 December 2022. to administer The medical cause of death was: 1a Bronchopneumonia with empyema due to invasive Group A streptococcal infection 4 CIRCUMSTANCES OF THE DEATH On 28 November 2022 Iona Buckingham was admitted to the Northampton General Hospital for oxygen therapy and feeding support in view of a diagnosis of bronchiolitis. A chest x-ray was performed on 29 November 2022 which showed right upper lobe pneumonia and some pleural effusion. Iona was escalated from high-flow nasal cannula oxygen to continuous positive airway pressure (“CPAP”). Iona continued to receive antibiotics and her condition appeared to improve. On 30 November 2022 she was stepped down from high-dependency care. At or around 14.00 on 3 December 2022 Iona was reviewed. She was observed to be in distress and was struggling to breathe. Iona was upgraded to a higher level of respiratory support. She was to be reviewed later for a possible need to return to CPAP. At or around 10.00 on 4 December 2022 a chest x-ray was performed. The x-ray showed a “whiteout” to the right lung and pleural effusion. Iona was moved to the High Dependency Unit where she returned to CPAP. Attempts were made to insert an endotracheal tube (“ETT”). A further x-ray showed that the ETT was not properly located and therefore a decision was made to re-site it. In 1 doing so, the ETT became dislodged. Iona went into cardiac arrest. Despite attempts to resuscitate her, Iona died at 18.37 on 4 December 2022. 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. – Following Iona’s death, the Northampton General Hospital NHS Trust conducted a Serious Incident Investigation. One of the recommendations made by the investigation panel was: “Children with pneumonia who are not improving after forty-eight hours of treatment or deteriorate at a later point should be suspected of having a pleural effusion and should get an immediate x-ray and chest ultrasound” That recommendation reflected advice provided on 29th November 2022 (the day after Iona’s admission to Northampton General Hospital) by the East Midlands Paediatric Critical Care Network: “We would like to inform you of a high number of cases of highly aggressive sepsis, linked to empyema, and positive culture for Group A Streptococcus in the region. This has caused significant morbidity and mortality. We advise early referral, aggressive management, high dose intravenous antibiotics, and early drainage of empyemas. Please have a low threshold for investigating any child with a secondary respiratory deterioration, especially with new onset of fever. Chest X-Ray and ultrasound will be beneficial.” At the inquest into Iona’s death, I heard evidence from the Trust’s Clinical Director of the Child Health Directorate who is also a Consultant Paediatrician. On the basis of the evidence I heard from the Clinical Director, I am satisfied that the Trust has taken action in respect of the recommendations made and more broadly have reflected upon the circumstances of Iona’s death. However, in respect of the recommendation set out above, I am concerned that there remains a risk that future deaths could occur unless further action is taken. The recommendation made by the investigation panel was that children with pneumonia who are not improving after forty-eight hours of treatment or deteriorate at a later point should get “an immediate x-ray and chest ultrasound”. However, the evidence I heard suggests this is not possible. I heard from the Clinical Director that as a district general hospital, Northampton General Hospital does not have access to a paediatric radiologist outside of 9am-5pm on Mondays and Fridays when such a specialist is either on duty or on-call. I heard evidence that in Iona’s case, a Consultant in ITU and Anaesthesia was able to perform an ultrasound scan at around 2pm on 4th December 2022 however this is not a facility that would routinely be available to the Trust and was not, in any event, part of that clinician’s core duties. I am concerned that a very unwell child who may require a chest ultrasound may not receive one ‘immediately’ and in fact may have to wait for a considerable period of time. For example, if the need arose over a weekend, that child may not receive an ultrasound scan for up to 48 hours. 2 I understand a reason why Northampton General Hospital does not have access to a paediatric radiologist outside of 9am-5pm on Mondays and Fridays may be due to the funding that is available. I am therefore sending this letter to the NHS Northamptonshire Integrated Care Board and to NHS England. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe 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 8th March 2024. 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: 1. . 2. Children’s Medical Emergency Transport, care of the Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust. I am also under a duty to send the Chief Coroner a copy of your response. 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 by the Chief Coroner. 9 12th January 2024 JONATHAN DIXEY 3
3 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.
Joanathan Dixey
Assistant Corner for the County
of Northamptonshire
Constabulary Block
Angel Square
Angel Street
Northampton
NN1 1ED
Dear Coroner,
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
4 March 2024
Re: Regulation 28 Report to Prevent Future Deaths – Iona Grace Buckingham
who died on 4 December 2022.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 12
January 2024 concerning the death of Iona Grace Buckingham on 4 December 2022.
In advance of responding to the specific concerns raised in your Report, I would like
to express my deep condolences to Iona’s parents and family. NHS England are keen
to assure the family and the coroner that the concerns raised about Iona’s care have
been listened to and reflected upon.
Your Report raises the concern that over access to paediatric radiologists outside of
9am to 5pm on Mondays and Fridays and that this may be due to available funding.
The Getting It Right First Time (GIRFT) Radiology programme provided input into this
response. GIRFT is a national programme designed to improve the treatment and care
of patients through in-depth reviews of services, benchmarking and presenting a data-
driven evidence base to support change.
The GIRFT radiology National Report was published in November 2020 and contains
twenty recommendations for NHS radiology services. While these aren’t specific to
paediatric radiology facilities, the imaging of children and young adults was reviewed
during the programme of visits to all NHS organisations providing radiology services in
England.
There is a national shortage of radiologists of all specialisms. Sir Mike Richards’
independent report “Diagnostics recovery and renewal” published in October 2020
identified a need for 2000 additional consultant radiologists. Workforce data is
collected by the Royal College of Radiologists (RCR) and published in an annual
census report. The most recent report demonstrates a 29% shortfall in consultant
radiologists across the UK. Regional analysis suggests that this shortfall is up to 35%
in the East Midlands. This is not due to a lack of interested applicants but to a historic
shortage of funded training places. NHS England are supporting Trusts to increase
reporting capacity by increasing the number of reporting radiographers and radiologist
trainees per financial year, via international recruitment initiatives and workforce
demand and capacity planning tools. NHS England are supporting Trusts to increase
reporting capacity by increasing the number of reporting radiographers and radiologist
trainees per financial year, via international recruitment initiatives and workforce
demand and capacity planning tools.
In June 2023, NHS England also published the NHS Long Term Workforce Plan, in
response to the current lack of sufficient workforce. The plan sets out how we will train,
retain and reform healthcare staff across the NHS over the next fifteen years, and is
underpinned by the biggest recruitment drive in NHS history.
Against this backdrop, 24/7 provision of specialist paediatric radiology services is
currently only available in specialist children’s hospitals and other tertiary centres. It is
rare for a district hospital to have more than one or two radiologists with an interest in
paediatric imaging and comprehensive cover is therefore not currently possible.
With reference to thoracic ultrasound in children for the purpose of identifying a pleural
fluid collection such as empyema, this is a technique performed not only by specialist
paediatric radiologists but also by some general radiologists, some advanced practice
sonographers and by some paediatric intensivists with appropriate training. NHS
England would not expect hospitals to have a formal rota for the provision of this
service, but to be able to seek help from a tertiary centre on the occasions on which
an ultrasound was needed and not available locally in a timely fashion.
NHS England’s National Imaging Strategy, published in November 2019, set out a
proposal to create collaborative imaging networks across England which is now in the
process of being implemented. One of the stated purposes of imaging networks is to
improve equity of access to specialist services which would include paediatric
radiology. Collaboration between paediatric radiologists in different hospitals already
exists, for example in the provision of reporting services for imaging studies conducted
in cases of Suspected Physical Abuse. The GIRFT programme will be visiting all 22
imaging networks during the course of 2024 and the provision of paediatric imaging
and reporting services will be on the list of topics to be reviewed.
I would also like to provide further assurances on national NHS England work taking
place around the Reports to Prevent Future Deaths. All reports received are discussed
by the Regulation 28 Working Group, comprising Regional Medical Directors, and
other clinical and quality colleagues from across the regions. This ensures that key
learnings and insights around preventable deaths are shared across the NHS at both
a national and regional level and helps us pay close attention to any emerging trends
that may require further review and action.
Thank you for bringing these important patient safety issues to my attention and please
do not hesitate to contact me should you need any further information.
Yours sincerely,
National Medical Director
Medical Directors Office
Cliftonville
Northampton
NN1 5BD
6 April 2024
Private and Confidential
Mr J Dixey
Assistant Coroner
The Guildhall
St Giles’ Square
Northampton
NN1 1DE.
Dear Mr Dixey
Letter to prevent future deaths
Thank you for your letter as specified above, your concerns have been reviewed by the
Trust and we are pleased to be given the opportunity to respond.
Following the incident in December 2022 the paediatric department have been working on
the actions that have been identified.
Currently the trust has one whole time equivalent radiologist that can undertake paediatric
radiology. One of the paediatric consultants is undertaking training in Point Of Care
Ultrasound (POCUS) and there is a charitable funds request for the purchase of a POCUS
ultrasound machine for the department. There is a further paediatric consultant who can
already undertake chest ultrasound scanning.
The radiology department are currently reviewing the possibility of joint recruitment of a
radiologist with a paediatric sub specialism working between Northampton General Hospital
NHS Trust (NGH) and University Hospitals of Leicester NHS Trust (UHL). There are currently
discussions with both UHL and University Hospitals of Northamptonshire NHS Group
(incorporating NGH and Kettering General Hospital NHS Foundation Trust) to review how the
providers within the system can work more collaboratively, reviewing current pathways and
provision.
There has been a suggestion that the current on call registrar / consultant radiologists are
trained in basic paediatric thoracic ultrasound. However, Radiology have expressed a
concern that this would not be achievable with current on call and staffing numbers and would
potentially underestimate the role and specialism of paediatric radiologists.
Given the low numbers of this type of investigation that would be required, trained staff may
not see sufficient numbers to maintain diagnostic competence. Trained paediatric radiologists
are short in number nationally. As a result of these uncontrolled variables, the provision of
24/7 trained paediatric radiology would be unachievable in all District General Hospitals.
Following the raising of the incident and acknowledged in the inquest, it was also identified
that there was a missed opportunity to perform a chest x-ray the previous day, and that
NGH-PO-1364
Version No:2
Page 1 of 2
June 2023
POLICY
information provided to support clinicians in children presenting with these conditions had not
reached all the clinical team. An action plan to address these issues was created, and
evidence has been submitted to complete the actions identified.
The issue that has been raised by the coroner in relation to the provision of paediatric
radiology is a much wider issue than NGH itself. A Regulation 28 Prevention of Future Deaths
has also been issued to the Integrated Care Board (ICB) as well as NHS England. The trust
will await these responses to develop future further actions if required.
Yours sincerely
Medical Director
NGH-PO-1364
Version No:2
Page 2 of 2
June 2023
POLICY
Haylock House Kettering Parkway Venture Park Kettering NN15 6EY Private and Confidential Mr J Dixey Assistant Coroner The Guildhall St Giles’ Square Northampton NN1 1DE 21st March 2024 Dear Mr Dixey Letter to prevent future deaths Thank you for your letter dated 12th January 2024 regarding Iona Grace Buckingham who sadly died on 4th December 2022. We understand that you sent the letter to Northants ICB due to your concerns about the funding arrangements for paediatric radiology outside of 9am-5pm on Mondays and Fridays. Following your letter, the ICB has been working closely with University Hospitals of Northamptonshire, NHSE Midlands, and Leicester, Leicestershire, and Rutland ICB to consider and support the pathways available for patients who need access to paediatric radiology outside of normal working hours. We understand that UHN is considering the possibility of joint recruitment of a radiologist with a paediatric sub specialism working between Northampton General Hospital NHS Trust and University of Leicester NHS Trust. We also understand that a paediatric consultant is being trained in Point of Care Ultrasound (POCUS) and there are charitable funds requested for the purchase of a POCUS ultrasound machine for the department. As an ICB we are happy to continue working alongside our acute colleagues to support a resilient safe model for patients. Yours sincerely Chief Medical Officer Headquarters: Haylock House, Kettering Park, Venture Park, Kettering, NN15 6EY Follow us on Twitter: @ICNorthants | Facebook: ICNorthamptonshire Instagram: @ICNorthamptonshire | LinkedIn: Integrated Care Northamptonshire
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