Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0299, written 19 Jun 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 Jun 2024 |
|---|---|
| Reference | 2024-0299 |
| Deceased | Selina Samarina |
| Coroner | Stephen Simblet |
| Coroner area | Essex |
| Category | Child Death (from 2015) |
| Organisation named | Mid and South Essex NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Mid and South Essex NHS Partnership Trust 1 CORONER I am STEPHEN SIMBLET KC assistant coroner, for the coroner area of Essex. 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 11th April 2023, I commenced an investigation into the death of Selina Samarina, aged 2. The investigation concluded at the end of the inquest on 28th May 2024. The conclusion of the inquest was that the deceased died of natural causes, the medical cause of death being that she had died from sepsis and pneumonia, with contributory factors of Down’s Syndrome and Upper Respiratory Tract infection. She died in Broomfield Hospital 4 CIRCUMSTANCES OF THE DEATH Selina had been brought into hospital by her parents with symptoms of fever, a rash and irritability. She was made an urgent referral and the sepsis protocol/ procedure was triggered. That should ordinarily lead to an examination by a senior doctor within an hour. In this case, a very junior doctor was sent over, in part because there was huge demand on the ward services and the available doctors of seniority were otherwise engaged with other patients. Selina’s diagnosis was thus arrived at by a relatively junior doctor, and other possible diagnoses such as sepsis or pneumonia were not addressed.There was no differential diagnosis. It was not until two and a half hours later that a doctor of appropriate seniority was available to assess Selina, by which time, as was consistent with the directions from the junior doctor, Selina had gone home with her parents. Evidence was given by the consultant that on that particular day, a Bank Holiday (Good Friday), there would normally be 12 doctors across the Emergency Department and Paediatrics Department, but on that day, there were only 7. This increased workload and the demand for services (which was at a normal level) had played a part in the consultant not being available to review Selina’s condition within the timescale mandated by the sepsis protocol, 5 CORONER’S CONCERNS 1 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) I was told in evidence that the Trust has now consolidated the staffing rotas for the Emergency Department and Paediatrics Department, so that it is now easier to see any deficit as one deficit across two departments. That does not however, address the situation of how and why a situation in which only 60% of the doctors are available for these important services. (2) I am concerned about the overall sufficiency of the staffing arrangements. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you [AND/OR 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 31 July 2024. 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 parents: ( ); nurse in charge Since the deceased was under 18, it may also be necessary to inform the LOCAL SAFEGUARDING BOARD (where the deceased was under 18)]. I have also sent it to Health Service England who may find it useful or of interest. 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 19th June 2024 2
1 response 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.
H.M Assistant Coroner
Mr Stephen Simblet KC
SEAX House
Victoria Road South
Chelmsford
Essex
CM1 1QH
Our Ref:
25 July 2024
Dear Mr Simblet KC
Regulation 28 Report to Prevent Future Deaths- Selina Samarina
I write further to your Regulation 28 Report to Prevent Future Deaths (PFDR) dated 19th
June 2024, relating to the Inquest of Miss Selina Samarina.
I have carefully reviewed your report and discussed your concerns with my colleagues in
the related specialties. I have set out below our response to the concerns raised.
Matters of Concern
(1) I was told in evidence that the Trust has now consolidated the staffing rotas for
the Emergency Department and Paediatrics Department, so that it is now easier to
see any deficit as one deficit across two departments. That does not however,
address the situation of how and why a situation in which only 60% of the doctors
are available for these important services.
(2) I am concerned about the overall sufficiency of the staffing arrangements.
The Trust has now improved how paediatric shifts are allocated to the Emergency
Department to ensure that it is adequately staffed. We have developed the governance
and management around staffing the Emergency Department so that we can promptly
escalate staffing issues before a shift commences, and appropriately manage and
mitigate any potential staffing concerns.
Whereas previously, the Paediatric Department had the responsibility of identifying and
allocating Paediatric shifts for Paediatric Emergency Department cover to staff, this task
is now undertaken by the Emergency Department team themselves. This change
ensures that the Emergency Department can identify which shifts are required by grade
and experience level according to the demand across the whole department. These shifts
are then approved within the care group and the Paediatric team assist in identifying
suitable cover where Paediatric skills are specifically needed.
1
The Emergency Department team are of course better placed to review the staffing
arrangements as they possess the knowledge of staff competencies within their teams
and can ensure that a safe staffing skill mix is met for each shift. This extends to not only
the medical teams, but also the wider staff groups including for example allied
professions and Advanced Nurse Practitioners.
Our rota-coordinators are completing regular checks throughout each day to maintain
safe staffing levels in the Emergency Department, and we hold early multi-disciplinary
planning meetings ahead of each weekend to carefully manage unforeseen risks and
issues such as sickness. The rota coordinators can request authority to put shifts out to
bank or agency if required, and if these cannot be filled, we have a clear escalation route
to the senior management teams to devise mitigation plans if required. However, in
practice this happens only occasionally as we are forward planning in good time and
bank shifts are usually filled.
As a comparison, and for assurance of the improvements we have made since this tragic
case, I have attached our audit data collated for the Easter period in 2024, names of the
staff members have been redacted. The data shows that very few shifts were unfilled
during this period, despite this often being a challenging time to cover shifts, and middle
grade and Consultant rotas were well filled. Senior doctor cover was as planned
especially on the late shifts going into the evening and overnight.
We will continue to monitor the staffing of the Emergency Department as part of our
ongoing audit programme, and we are confident that we are now in a much-improved
position.
We are grateful for you bringing this issue to our attention and are grateful for the
opportunity to learn from these events. We hope that the action we have taken, and will
continue to take, has provided assurance that your concerns are being addressed.
If you have any further concerns or you would like to discuss this case further, please do
not hesitate to contact me.
Yours sincerely
Medical Director, Deputy CMO and Consultant ENT Surgeon
Mid and South Essex NHS Foundation Trust
Enc Audit data
2
3 4 5 6 7 8 9 10
See every Prevention of Future Deaths report matching Mid and South Essex NHS Foundation Trust, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.