Tommy Gillman

Inquest touching the death of Tommy Jay Gillman 

Response  of Sherwood  Forest  Hospitals  NHS  Foundation  Trust  to  Regulation 
28  report to prevent future deaths. 

This is the organisational response from Sherwood  Forest Hospitals NHS Foundation 
Trust to  the  Regulation  28:  Report to  Prevent  Future  Deaths  issued  by HM  Coroner, 
following the conclusion of the inquest touching the death of Tommy Jay Gillman. 

We  reiterate  our  condolences  and  apologies  to  Tommy's  family,  and  we  hope  this 
response  which  considers  the  matters  of concern  raised  by  HM  Coroner,  provides 
reassurance  that  the  Trust  recognises  and  acknowledges  its  shortcomings  and  is 
committed to  ensuring that we  learn from this to  prevent future deaths. 

Matters of concern raised within the report and responses for each point are as follows: 

1) At times  of high  pressure  and  business,  the  Paediatric  nursing  complement 
is insufficient in the Emergency Department. There are inexperienced Paediatric 
nurses trying to manage a very high workload, without senior nurse support to 
try  and  increase  staffing  levels  on  a  shift.  The  Facing  the  Future  (RCPCH} 
standards for levels of Paediatric nursing are  not met. 

for  care  applicable 

The  Royal  College  of  Paediatrics  and  Child  Health  (RCPCH)  Facing  the  Future: 
Standards  for  Children  in  Emergency  Care  Settings  (2018)  describe  national 
in  Emergency  Care  settings. 
standards 
to  children 
Recommendation  10  of these  standards  states  that  every  Emergency  Department 
(ED) must be staffed with two registered children's nurses on each shift.  However, the 
Care  Quality Commission  (CQC) and  RCPCH  recognise  the  challenges  in  recruiting 
Registered  Children's  Nurses  (RNC)  and  are  working  to  support  services  through 
provision of guidance and an  audit tool  kit. 

As  a  district  general  hospital  recruiting  of  RNC's  is  challenging  despite  active 
recruitment.  Sherwood  Forest  Hospital  (SFH)  acknowledge  that  it  is  unable  to  meet 
the workforce standards outlined by the RCPCH. The following mitigations are in place 
in  line with CQC guidance: 

•  A profile of when children and young people attend the ED over a 1-year period 

has been obtained to ensure that RNC's are rostered on at peak times. 

•  A minimum  set of core  competencies that adult  nurses  must have  completed 

prior to caring for a child  or young  person  has been  agreed as follows: 

a.  Minimum of 18 months post registration  experience 
b.  Completion of paediatric intermediate life support training 
c.  Completion of the  internal 2-day paediatric study days 
d.  Completion of paediatric sepsis e-learning package 
e.  Following  completion  of  the  above,  an  additional  day  shadowing  a 

trained  Registered Children's Nurse will  be  completed. 

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 •  RNC staffing within the ED  is recorded on the Trust risk register as a significant 
risk and  is  reviewed  monthly by  the  specialty and  Trust  Risk  Committee.  This 
has led to the development of the rotational  post (see below). 

•  Continuous collaborative working  between  ED  and  the  division of Women  and 
Children to develop a rotation pathway for RNC's is planned to be in  place from 
October 2024. 

•  ED Adult  Nurse  released  to  complete  Paediatric  Nurse  Training  (18  months) 

due to complete in  September 2024.  This will  increase staffing by 1WTE. 

Sherwood  Forest  Hospital  provide  all  newly  qualified  RNCs  with  a  nominated 
preceptor,  qualified  in  the  same  discipline  of  nursing  with  at  least  12  months 
experience. All  registered  nurses  within  the  preceptorship  programme  undertakes  a 
minimum period of 4 weeks supernumerary practice which includes a Trust Orientation 
Day  and  Nursing  and  Midwifery  Induction  Programme.  During  this  supernumerary 
period the RNC preceptee is provided with  a local induction pertinent to the ED with  a 
particular  focus  on  children  and  young  people.  A  preceptor  will  integrate  Trust 
standards,  competencies,  objectives  and  Trust  CARE  values  into  practice  and 
contribute to an environment which facilitates learning for the Preceptee to ensure they 
have appropriate skills to competently undertake their role. 

The  ED  senior leadership team  have  reviewed  the  escalation  processes  in  place for 
proactively reviewing  and  escalating nursing staffing concerns. 

Healthroster,  a system  for producing  rosters  which  take  into  account an  employee's 
skills  is  used  to  proactively to  maximise  the  likelihood  that each  department has the 
appropriate number of staff whilst ensuring there is a safe skill  mix. The  ED children's 
area rota is produced  by the Band 7 lead  nurse a minimum of 6 weeks in  advance. An 
additional  Band  5  RN  shift  has  been  added  to  the  roster  from  4pm-2am  to  support 
attendances  at  peak  times.  Following  the  Inquest  improvements  have  been  made 
locally to  the  Healthroster system to  highlight specific nursing  shifts for the children's 
area.  This  change enables clear identification  of where  there are gaps  in  RNC  cover 
thus  enabling  the  ED  leads  to  ensure  adult  nurses  with  the  minimum  paediatric 
competencies are on  duty. 

It  is  not  possible  to  predict  sickness  and  short-term  unplanned  absence,  therefore 
changes  to  staffing  availability  may  need  to  be  escalated  and  acted  upon  at  short 
notice. At the  time  of Tommy's  attendance,  the  Band  7  leads  were  rostered  on  day 
shifts  and  included  within  the  ED  staffing  figures.  In  April  2024,  a  new  band  7 
supervisory  Nurse  in  Charge  (NIC)  role  has  been  implemented  within  ED  to  ensure 
there  is  visible  senior support available  24  hours  a day for the  entire  department. At 
present,  the  NIC  is  included  within  staffing  figures,  however from  July 2024  this  role 
will  be supernumerary. Within this role the NIC is required to ensure staff allocation for 
their  shift  and  the  following  shift  meets  the  minimum  requirements  and  will  be 
responsible  for  escalating  any  concerns  to  the  Division  or  Duty  Nurse  Manager to 
identify additional staff from  other clinical areas in  the Trust to support ED. 

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 2)  Handovers  and  key  conversations  between  staff,  both  nursing  and  medical 
staff,  in  ED  and  with  Paediatric  staff  are  not  routinely  documented,  and 
outcomes  from  handovers  and  escalations  do  not  result  in  clear action  plans 
and allocated tasks. 

The  Trust  recognise  the  importance  of  ensuring  verbal  discussions  in  relation  to  a 
patient's care are documented accurately and  contemporaneously within  the  patients 
records  and  that  effective  handovers  are  undertaken  to  ensure  unambiguous 
treatment plans are agreed. 

SBAR (Situation,  Background, Assessment and  Recommendation)  is  the  recognised 
structure  for communication  and  handing  over patients  for staff.  The  ED  Registered 
Nurse  local  induction  covers  structured  handovers  and  accountability  handover and 
staff are provided with examples of how to use handover effectively.  Whilst structured 
handovers  must  be  used  for  any  verbal  handover  there  was  no  documentation 
requirement to confirm whether this had taken place at the time of Tommy's attendance 
to the  ED.  The ED  Paediatric triage document has been  updated and  nurses are now 
required to confirm  an  SBAR verbal  handover has been  provided: 
IEMAS call sign: 

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As$igned 
Nurse ED  (Prinll 

AWgned 
Nurse ED  (PrJnll 

Sigfled 

Signed 

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Compliance  with  staff signing  the  accountability  handover is  to  be  monitored  via  the 
Emergency  Department  Quality  and  Safety  Assurance  Paediatric  Monthly  Audit 
registered  on  AMAT  (clinical  audit  assurance  software)  and  any  omissions  are 
escalated  in  a timely  manner to  the  appropriate  managers.  The  first  cycle  of audit  is 
June 2024. 

SBAR  is  also  a  recognised  structure  for medical  handover and  all  Sherwood  Forest 
clinical  staff  are  required  to  utilise  a  structured  handover  to  ensure  effective  and 
assertive  communication.  In  addition,  use  of  a  structured  handover  ensures  clear 
recommendations  are  provided,  preventing  ambiguity  through  encouraging  clinical 
staff  to  repeat  the  information  back  to  the  provider  to  confirm  understanding  and 
allocation  of tasks. 
In  addition,  changes  to  the  medical  model  and  provision  of  a 
designated  Tier  3  (previously  referred  to  as  a  Registrar  or Middle  Grade)  or above 
Doctor to  oversee the care  of all  children  reduces  the  number of handovers  required 
and  improves the continuity of care. 

in  ED  have  been 

All  clinical  staff  working 
that  accurate  and 
contemporaneous  record  keeping  is  mandatory,  in 
line  with  Sherwood  Forest 
Hospitals  Clinical  Record  Keeping  Standards  Policy  (2023).  To  gain  assurance  that 
medical  documentation  is  being  completed  contemporaneously  to  a  high  standard, 
regular reviews are undertaken, and feedback, education and support provided to any 

instructed 

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 individuals  as  deemed  necessary.  Additionally,  nursing  documentation  is  audited 
monthly,  and  the  audit  has  a  specific question  to  confirm  that  all  entries  made  by  a 
student  nurse  are  countersigned  by  a  registered  professional  thus  ensuring  a 
registered  nurse has oversight of their documentation. 

3)  The  system  for  recognising  an  ill  baby  in  Paediatric  ED  is  not  robust- from 
the  point  of  attendance,  through  timely  triage,  timely  escalation,  and  joint 
assessment by senior ED and  Paediatric staff. 

SFH  provides  medical  and  nursing  colleagues  with  an  appropriate  range  of training 
specific  to  their  individual  roles.  In  relation  to  recognising  an  unwell  child  or young 
person  in  a timely manner,  there are a number of tools  and  processes  in  place  to  be 
used alongside clinical judgement including but not limited to: 

Observations recorded  and  calculated using PEWS on  Nervecentre. 

At the  time  of Tommy's  attendance  to  ED  children  and  young  people's  observations 
were  recorded  and  calculated  manually  on  paper  using  the  Paediatric  Observation 
Priority  Score  (POPS).  During  the  Trust's  investigation  concerns  regarding  the 
reliability of this were raised and following extensive consultation between Emergency 
Medicine  and  Paediatrics  this  was  discontinued.  Children  and  young  people's 
observations  are  now  recorded  on 
'Nervecentre'  a  digital  system  that  allows 
observations  to  be  recorded  and  calculated  electronically  using  the  Paediatric  Early 
Warning System (PEWS). 

To support the visibility of observations every member of clinical staff now has access 
to  a  handheld  device  to  record  and  view  observations  in  real  time.  In  addition,  as 
Nervecentre  is  used  across  the  organisation  for  children  and  young  people,  the 
Paediatric specialty have the ability to access patients' observations remotely. 

frequency  in  real 

When considering visibility of observations, a further review was undertaken following 
the  Inquest and  it was  recognised  that the  methodology to  monitor whether patients 
were  receiving  observations  at  the  required 
time  required 
improvement. Within both the major's area and children's and young people area large 
screens which provide a Nervecentre oversight dashboard of a specific task have been 
installed.  The  location  of  these  was  carefully  considered  to  ensure  there  was  no 
information  governance  risk  whilst  ensuring  they  were  in  a  location  easily  visible  to 
departmental staff.  Each  screen  is  set to  live observation view which  enables staff at 
a glance to  identify any patient with  an  elevated  PEWS and  time  repeat observations 
are  required  in  line  with  PEWS  escalation  guidance.  Each  patients  current  PEWS 
score  has  a  coloured  background  which  automatically  updates,  White  represents 
scores  1-5,  Green  6-8, Amber 9-12  and  Red  13 and  above.  In  addition,  the time due 
changes to  red  if observations become overdue thus facilitating  easy identification of 
which  patients are acutely unwell. 

With the introduction of the new NIC role, there is now a designated accountable Band 
7 lead responsible for ensuring these screens are effectively utilised and monitored to 

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 ensure  the  staff caring  for  patients  with  elevated  PEWS  Scores  are  supported  by  a 
senior member staff. 

Children and young people escalation tool. 

In  conjunction  with  changes  to  visibility  of  observations,  and  implementation  of  a 
supervisory  NIC  role  the  Children  and  Young  People  escalation  tool  has  been 
reviewed  to  ensure  there  is  clear  guidance  on  escalation  triggers  and  the  actions 
required.  One of the specific triggers  listed  is  in  relation  to  triage times thus ensuring 
all  children  and  young  people  provide  timely  reviews.  A  copy  of the  Children  and 
Young  People escalation plan within appendix 1 has been circulated to all clinical staff 
within  the  ED,  however staff have  been  instructed  this  is  not to  be  used  in  isolation 
and  clinical  judgement  and  parental/carer  concerns  should  always  be  taken  into 
consideration.  Use of the  updated  Children  and  Young  People escalation  tool  will  aid 
timely  escalation  of  any  issues  identified,  ensure  senior  support  is  available  and 
appropriate plans implemented to maintain patient safety. 

Paediatric sepsis e-learning. 

The Trust paediatric e-learning training package has been re-introduced as mandatory 
for  all  medical  and  nursing  staff  within  the  ED  from  1st  May  2024.  Compliance  is 
monitored  at  divisional  level  fortnightly  and  reported  to  the  Trust  Sepsis  group  for 
assurance. 

In  addition  to  the  above  training  currently  in  place  to  support  staff,  the  Paediatric 
Sepsis 6 Care Bundle, a document to screen and identify children at risk of sepsis and 
outline  the  appropriate  treatment  is  under  review  by  Emergency  Medicine  and 
Paediatrics  to  be  completed  by  August  2024.  The  proposed  changes  include 
specifying that patients with Trisomy 21  and  babies  under the age of 3 months are at 
higher  risk  of  developing  sepsis  to  ensure  this  is  taken  into  consideration  when 
deciding whether to trigger commencement of sepsis treatment. 

Implementation of core competencies to care for Children and Young  People. 

Recognition of an  acutely unwell child is the responsibility of both medical and  nursing 
staff within the department. As previously set out, a set of core competencies that adult 
nurses  must have  undertaken to  care for children  and  young  people  is  in  place.  The 
Standard  Operating  Procedure for Children  and Young  People within  the  Emergency 
Department,  (see appendix 2) has been  updated to  reflect the  new minimum training 
requirements for medical staff to ensure they have the appropriate skills to effectively 
identify  an  unwell  child.  Staff who  do  not  meet these  criteria  are  no  longer directly 
responsible for the care of children and young  people in  the  ED. 

Increase in  senior staff availability. 

At the time of Tommy's attendance, there was no supervisory Band 7 Nurse in Charge 
shift.  This  role  is  now  embedded  into  the  Healthroster,  with  shifts  filled  for  the 

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 preceding six weeks.  This role provides 24-hour senior nursing support to staff caring 
for children. 

Following the Inquest, a further review of Paediatric ED staffing with specific reference 
to  medical  cover was  undertaken  and  the  medical  model  of clinicians  responsible for 
the  care  of  children  and  young  people  has  been  amended.  The  ED  now  has  a 
designated Tier 3 or above Doctor responsible for caring for this cohort of patients with 
the support of the consultant in  charge. 

A Senior Review and  Out of hours ED Consultant Call Criteria has been produced and 
implemented  to  provide  additional  guidance  as  to  when  a  Consultant  should  be 
contacted  out  of hours.  This  has  been  shared  with  all  Clinicians.  Consultants  have 
confirmed they are engaged and actively promote and encourage staff to contact them 
for support and  guidance.  It is  however acknowledged  that the  criteria  set out within 
appendix  3  is  not  an  exhaustive  list  and  any  concerns  which  staff  feel  requires 
discussion with  a Consultant should continue to take place. 

Location for caring for children when the CYP area is closed out of hours. 

Previously,  children  who  required  care  within  ED  outside  the  hours  of 09:00-02:00 
were  cared  for  in  various  locations  across  the  department.  This  practice  has  been 
reviewed  and  out of hours  all  children  presenting  with  a  medical  complaint are  now 
cared for within a designated area within Majors. Caring for children and young people 
in  a specific area  enables  the  Tier 3  Doctor responsible  to  have  improved  oversight 
and  promotes visibility of the  patients. 

Collaborative working with the Paediatric Specialty. 

Sherwood  Forest  Hospital  actively promote  interprofessional  working.  Within  the  ED 
children  and  young  people  are  regularly  referred  to  the  Paediatric  specialty  team 
through  a  verbal  referral  process.  Through  utilisation  of  a  structured  handover 
clinicians  can  obtain  the  required  information  to  agree  a  plan  of care  and  confirm 
allocation of any tasks and the priority for these.  Joint assessments with  a member of 
both  Paediatrics  and  ED  present  at  the  same  time  are  undertaken  where  deemed 
necessary,  for  example  an  acutely  unwell  child  in  the  resuscitation  area  requiring 
intubation. 

A Children and Young People's Working Group has been established with membership 
from  senior medical,  nursing  and  operational  staff from  the  Urgent Emergency Care 
and  Women's  and  Childrens  Divisions.  The  group  is  reviewing  current  policies  and 
Standard  Operational  Procedures  relating  to  Children  and  Young  People  to  include 
opportunities for joint working, clinical pathways,  recruitment and operational working. 

There  is  continuous  cross-specialty  teamwork  between  the  Emergency  Department 
team  and  Paediatrics to  ensure  patients receive  the  best possible  care  utilising each 
learning  and  system 
area's  expertise.  Collaborative  reviews 
improvements supporting timely implementation of escalation where required. 

facilitate  shared 

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