Meha Carneiro

Inquest touching the death of Meha Carneiro. 

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 Miss Meha Carneiro. 

We  reiterate  our condolences and  apologies to  Miss  Carneiro's family,  and  we  hope 
this  response  that  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}There  were  insufficient trained  Paediatric  nurses  on  duty  in  the  Emergency 
Department  (ED},  on  the  day  of Meha's  admission,  and  there  was  no  effective 
escalation to senior nursing staff to  highlight this. 

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 
to  children 
standards 
in  Emergency  Care  settings. 
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  RNCs  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 RNCs 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. 

•  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). 

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 •  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  by 
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. 

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  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 ED 
Children  and  Young  People  attendance  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 Meha's attendance, the band 7 leads were rostered on day shifts 
only  and  included  within  the  ED  staffing  figures. A new band  7 supervisory  Nurse  in 
Charge  (NIC)  role  has  been  implemented  within  ED  to  ensure  there  is  now  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 Trust's minimum requirements described above 
and are responsible for escalating any concerns to the Division or Duty Nurse Manager 
to  identify additional workforce from  other clinical areas in  the Trust to support ED. 

2) There was overall a lack of recognition of how unwell Meha was on admission 
and  over the  subsequent hours  prior to  her death- this  included  both  nursing 
and medical staff in  ED: 

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 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 Meha'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 

2 

 Medicine  and  Paediatrics  this  was  discontinued.  Children  and  young  peoples' 
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  review patient's 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's  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  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  the  time  repeat 
observations  are  required  in  line  with  PEWS  escalation  guidance.  Each  patient's 
current PEWS score  has a coloured  background which  automatically updates, White 
represents  scores  1-5,  green  is  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  supervisory  nurse-in-charge  role  there  is  now  a 
designated  accountable  band  7  lead  responsible  for  ensuring  these  screens  are 
effectively utilised  and  monitored  to  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 (GYP) escalation tool  has  been 
reviewed  to  ensure  there  is  clear  guidance  on  escalation  triggers  and  the  actions 
required. A copy of the  Children  and Young  People escalation  plan  within appendix 1 
has been circulated to all employees 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  made  re-introduced  as 
mandatory  for  all  medical  and  nursing  staff  within  the  ED  from  1st  May  2024. 

3 

 Compliance  is  monitored  at  divisional  level  fortnightly  and  is  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 Meha's attendance,  there was  no  supervisory band  7 nurse  charge on 
shift.  This  role  is  now  embedded  into  the  Healthroster,  with  shifts  filled  for  the 
preceding  six weeks.  The  NIC  role  provides  24-hour senior nursing  support to  staff 
caring for children. 

Within  the  action  plan  review  provided  to  HM  Coroner  immediately  following  the 
Inquest,  reference  to  a  further  review  of  the  Paediatric  ED  staffing  with  specific 
reference to medical cover was made. This took place on the 10th April 2024. The Trust 
can  confirm  that following  this  review the  medical  model  of clinicians  responsible  for 
the  care  of Children  and  Young  People  has  been  amended,  and  a Tier  3  or above 
Doctor is  now responsible for caring  for this cohort of patients with  the support of the 
consultant in  charge. 

Senior Review and  Out of hours ED Consultant Call  Criteria have 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.  These  criteria,  set  out  within  appendix  3,  are  not  an 
exhaustive list and staff are aware that any concerns they feel  require discussion with 
a Consultant must lead to contact being  made. 

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

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 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  practise  has  been 
reviewed and out of hours all children 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. 

3)  Whilst  switching  from  use  of  POPS  to  PEWS  in  ED,  is  likely  to  assist  in 
ensuring repeat observations in a sick child, a PEWS of 6-8 only triggers review 
by  a junior rather than  a senior ED  Doctor,  the  former  less  likely to  recognise 
severity of illness and respond  appropriately. 

Following  the  Inquest, the Trust acknowledged  the additional  concerns  raised  by HM 
Coroner and  in  conjunction  the  ED  team  and  Paediatric specialty  reviewed  national 
guidance regarding whom a child or young person should  be escalated to based upon 
their PEWS  score.  The Trust PEWS  escalation  guidance  now states a patient with  a 
PEWS between 6-8 or a single observation in one parameter that scores a 3 will trigger 
a  review  by  a  minimum  of a  Tier  3  or  above  Doctor will  be  made  aware  within  30 
In  addition  to  acting  on  PEWS  scores  and  clinical  concerns, 
minutes  of escalation. 
staff are empowered  to  escalate  parental  or carer concerns.  This  has  been  reflected 
in the ED Paediatric Triage Documents. Upon completing the review if the Doctor feels 
additional  support  and  guidance  is  required  there  is  always  a  consultant  on  call 
accessible.  Additionally,  the paediatric team can  be contacted for specialist support. 

Implementation of the new medical  model  providing minimum Tier 3 cover to oversee 
the  care  of  children  and  young  people  enables  these  changes  to  be  effectively 
implemented.  The  updated  PEWS  escalation  guidance  has  been  cascaded  to  all 
medical and  nursing staff working within the  ED  and  paediatrics. 

4)  There was  insufficient and  ineffective  handover between  medical  staff,  with 
lack  of documentation  of key  information,  and  agreed  clinical  plans- between 
doctors in  ED, and  between ED and  Paediatric staff. 

During  the  Inquest  it  was  acknowledged  that  ineffective  verbal  handovers  between 
Doctor's  and  missed  opportunities 
to  provide  contemporaneous  medical 
documentation directly impacted the care provided to Meha. 

The additional information submitted  by the Trust to  HM  Coroner following the  Inquest 
detailed  information  regarding  use of SBAR (Situation,  Background, Assessment and 
Recommendation) for handovers. SBAR is a recognised method for medical handover 
and  training  on  structured  handovers  is  routinely  provided  to  all  medical  and  nursing 
staff.  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 
information  back  to  the  provider  to  confirm 
encouraging  staff  to  repeat  the 
understanding. 

5 

 The  ED  Registered  Nurse  local  induction  covers  SBAR and  accountability handover 
and  staff are  provided  with  examples  of how to  use  SBAR effectively.  Whilst SBAR 
must  be  used  for  any verbal  handover there  was  no  documentation  requirement  to 
confirm whether this had taken  place at the time of Meha'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: 
IEIMAS cal.I sign: 

EMAS ,pin: 

I S8AR 

A$slqned 
Nur!e E.O. {Pr  nt) 

Assigned 
Nurr.e  E.D . (Pnnt) 

Siglll!d 

Signed 

O;i e 

/T,me. 

OMe 

/Ti~ 

lruualS 

lninal~ 

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. 

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 
individuals as deemed required. 

instructed 

The  changes  to  the  medical  model  previously  described  means  that  there  is  a 
designated  Tier 3 or above  Doctor overseeing  the  care  of all  children.  The  Tier 3 or 
above  doctor  will  lead  and  manage  handovers  between  specialities  and  at  shift 
change,  thus  reducing the  number of handovers required  and  improving  continuity of 
care. 

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