Barking and Dagenham Child Death
Overview Panel
Annual Report 2012-2013
1
Contents
Introduction……………………………………………………………………………..
3
Terms of Reference
Organisation and resourcing of Child Death Overview Panel ……………….
3
North East London (seven borough) Child Death Overview Panel Meetings
3
The Coronial Service ………………………………………………………………
4
Core membership …………………………………………………………………
4
Definition of child death categories ….………………………………………….
5
Demographic Profile ………………………………………………………………….
5
Overview of notified cases……………………………………………………………
6
Number of deaths in Barking and Dagenham …………………………………
6
Child deaths received by quarter …………………………………………………
6
Unexpected deaths ………………………………………………………………..
7
Breakdown according to age………………………………………………………
7
Ethnicity Breakdown…………………………………………………………….....
8
Sudden Unexpected Deaths in Infancy (SUDI) …………………………….....
8
Commentary of cases reviewed ……………………...............................………….
8
Number of meetings held ………………………………………………………...
8
Number of reviews completed …………………………………………………...
9
Neonatal deaths ……………………………………………………………………
10
Sudden Unexpected Deaths in Infancy ………………………………………….
10
Unexpected deaths …………………………………………………………………
11
Expected deaths ………………………………………………………………...….
11
Time between the child’s death and completing the review ………………...….
11
Modifiable Factors and Recommendations……………………………………..........
12
Actions taken following the reviews of child deaths ..…………………………….....
12
Achievements 2011-12 …………………………………………………………..……
13
Future work 2012-13 …………………………………………………………………...
14
Appendix 1 – Modifiable Factors to child death reviews 2012-13 .………………...
15
2
1. Introduction to Child Death Overview Panel
1.1. Terms of Reference
Through a comprehensive and multi agency review of child deaths, the Child Death
Overview Panel (CDOP) aims to understand how and why children die in Barking
and Dagenham and use the findings to take action to reduce the risks of future child
deaths and to improve the health and safety of the children in the area.
Regulation 6 of the Local Safeguarding Children Boards Regulations 2006, set out
the function of the Local Safeguarding Children Board (LSCB) in relation to child
deaths, made under section 14(2) of the Children Act 2004. The LSCB is
responsible for:
a. collecting and analysing information about each death with a view to identifying—
(i)
any case giving rise to the need for a review mentioned in regulation
5(1)(e);
(ii)
any matters of concern affecting the safety and welfare of children in the
area of the authority;
(iii)
any wider public health or safety concerns arising from a particular death
or from a pattern of deaths in that area; and
b. establishing procedures for ensuring that there is a coordinated response by the
authority, their Board partners and other relevant persons to an unexpected
death.
Barking and Dagenham CDOP is asked to categorise the likely cause of death,
recorded the event that caused the death and any modifiable factors.1
1.2. Organisation and resourcing of CDOP
As of April 2013, the management of the CDOP Manager transitioned from the NHS
to the Council and is jointly funded by the NHS Barking and Dagenham Clinical
Commissioning Group (NHSBD CCG) and London Borough of Barking and
Dagenham (LBBD).
1.3 North East London (seven borough) CDOP Meetings
Barking and Dagenham is a member of the seven borough north east London CDOP
meeting that has been developed to share learning, agree a minimum data set so
statistical analysis of trends, emerging themes and common modifiable factors can
be better understood and share and learn from actions undertaken in response to
emerging themes and modifiable factors. The seven boroughs consist of Barking
and Dagenham, Havering, Redbridge, Waltham Forest, Hackney and the City,
Newham and Tower Hamlets.
Modifiable factors – is where there are factors which may have contributed to the death. These
factors are defined as those which, by means of nationally or locally achievable interventions, could
be modified to reduce the risk of future child deaths.
1
3
1.4 The Coronial Service
Barking and Dagenham is working closely with Waltham Forest Coroner’s Court to
better develop the process to obtain full post mortems so that reviews are thorough
and timely.
On 25 July 2013, a new code of standards2 was issued aimed at speeding up
inquests into deaths. It is anticipated that most inquests in England and Wales will
be completed within six months. This follows complaints that bereaved families have
had to wait years for a hearing.
1.5 Core Membership
The position of chair has been taken over by Matthew Cole, Joint Director of Public
Health.
We have also welcomed Sue Newton, Designated Nurse Safeguarding and Dr
Mahima Ruprasinghe, as Interim Designated Paediatrician for child deaths.
The full membership is made up of:
Matthew Cole
Joint Director of Public Health and CDOP Chair
Roselyn Blackman
CDOP Manager, LBBD
Dr Mahima Rupasinghe
Interim Designated Paediatrician for Unexpected
Deaths in Childhood, NHSBD
Designated Nurse Safeguarding, NHSBD CCG
Sue Newton
2
Avraamis Avraam
Group Manager for Safeguarding, Quality and
Reviews representing Barking and Dagenham
Safeguarding Children’s Board
Chris Martin
Divisional Director for Complex Needs and Social
Care, Children’s Directorate, LBBD
Kevin Jeffery
Detective Inspector, Child Abuse Investigation
Team, Metropolitan Police Service
Claire Butler
Children’s Safeguarding Barking Havering
Redbidge Univerisity Hospitals NHS Trust
Dr Junaid Solebo
Consultant Paediatrician Named Doctor for
Safeguarding Children & Young Adults. Barking
Havering Redbridge University Hospitals NHS
Trust
Dr Richard Burack
Named GP NHSBD
https://www.gov.uk/government/news/major-overhaul-of-coroner-services-in-england-and-wales
4
Other members are co-opted as and when necessary, to provide expert opinion and
to contribute to the discussion of certain deaths.
1.6 Definitions of child death categories
The following definitions are the areas CDOP will provide commentary on reviewed
cases in this report.
o
Neonatal death - is a death of a live born infant within the first 28 days of life.
o
Sudden Unexpected Death in Infancy (SUDI) – is marked by the sudden death
of an infant, under 2 years old. The death is unexpected by history and remains
unexplained after a thorough forensic autopsy and detailed death scene
investigation.
Sudden unexpected, unexplained death – where the pathological diagnosis is
either SIDS or ‘unascertained’ at any age.
o
Unexpected Death - is a death of an infant or child (less than 18 years old)
which:
Was not anticipated as a significant possibility for example, 24 hours before the
death; or
Where there was a similarly unexpected collapse or incident leading to or
precipitating the events which led to the death.3, 4
o
2
Expected Death - an expected death is defined as one where the patient's
demise is anticipated in the near future and plans have been put in place and the
cause of death is known. There are no suspicious circumstances to suggest that
anything untoward has occurred and the decision that death is expected will be
clearly documented in clinical notes. This will be separate from a "do not
resuscitate order".
Demographic Profile
In the 2011 Census, the population of Barking and Dagenham was recorded as
185,911, with a total of 53,544 children aged 0-18 years. This represents 28.8% of the
population. Table 1 on the next page gives a breakdown of the total children and shows
the number and percentage increase according to age.
3
PJ. Fleming, P.S. Blair, C. Bacon, and P.J. Berry (2000) Sudden Unexpected Death in Infancy. The
CESDI SUDI Studies 1993-1996. The Stationary Office. London. ISBN 0 11 3222 9988.
4 Royal College of Pathologists and the Royal College of Paediatrics and Child Health (2004) Sudden
unexpected death in infancy. A multi-agency protocol for care and investigation. The Report of a
working group convened by the Royal College of Pathologists and the Royal College of Paediatrics
and Child Health. Royal College of Pathologists and the Royal College of Paediatrics and Child
Health, London. www.rcpath.org.
5
There has been a significant percentage increase of 48.91% in 0-4 year olds.
Table 1
Total number of children by age and increase by number and
percentage
All People
0-4
5-7
8-9
10-14
15
16-17
2011
2001
185,911
18,676
8,989
5,342
12,757
2,534
5,246
163,944
12,542
7,479
4,984
11,107
2,242
4,441
Number
increase/
decrease
21,967
6,134
1,510
358
1,650
292
805
% increase /
decrease
13.40%
48.91%
20.19%
7.18%
14.86%
13.02%
18.13%
The ethnic mix has changed since the 2001 census. The White British group fell from
82.5% of the total population to 50.5%, compared to increases in Black African (from
4.4% to 15.4%) and White other groups (from 2.6% to 7.8%). Asian and other ethnic
groups are now estimated at 17.5%, compared to 6% in 2001.5
3.
Overview of Notified Cases
Deaths that have been notified to the Barking and Dagenham CDOP are not all
reviewed and closed during the same year of notification. The Department of Education
recognise it may take a number of months (or years in some cases) to gather sufficient
information to be able to fully review a child’s death. This can be due to criminal
proceedings, autopsies, coroners’ reports, serious incidents (SIs) and serious case
reviews (SCRs). Barking and Dagenham CDOP will await the conclusion of these
investigations before a review is undertaken.
3.1 Number of deaths in Barking and Dagenham notified to the CDOP
In 2012-13, there were 24 child deaths reported to the CDOP. Table 2 gives a
breakdown of child deaths reported to the CDOP since its establishment in 2008. This
figure has fluctuated between 19 and 32 during the past five years.
Table 2
BD
2008-09
2009-10
2010-11
2011-12
2012-13
32
24
19
27
24
3.2 Child death notifications received by quarter
Table 3 below shows this year is the first time since the establishment of CDOP we have
5
http://www.lbbd.gov.uk/CouncilandDemocracy/Census/Documents/130122%20LBBD%202011%20C
ensus%20Key%20Statistics%20FINAL_update.pdf
6
seen a high number of deaths over Q2 and 3. In previous years Q3 has returned the
highest number of child deaths.
Table 3
Q1
Q2
Q3
Q4
Total no
of child
deaths
2008-09
4 (13%)
8 (25%)
11 (34%)
9 (28%)
2009-10
6 (25%)
3 (12%)
10 (42%)
5 (21%)
2010-11
3 (16%)
5 (26%)
6 (32%)
5 (26%)
2011-12
7 (26%)
5 (18.5%)
10 (37%)
5 (18.5%)
32 (100%)
24 (100%)
19 (100%)
27
(100%)
2012-13
4
8
8
4
24
3.3 Unexpected deaths
Of the 24 deaths reported to CDOP this year, there were 9 unexpected deaths. Eight
rapid response meetings were held and a rapid response discussion to the one where
CDOP did not hold a meeting.
3.4 Breakdown according to age.
Diagram 1 shows the breakdown of child deaths according to age of child deaths
reported to CDOP during 2012-13.
The highest proportion of deaths, 46% (11), is within the neonatal period, 0-27 days.
Children under 1 year of age represent 67% (16) of the total child deaths. This is
consistent with previous years and with national figures.
Diagram 1
4%
8%
(1)
(2)
Breakdown of child deaths
according to age
46%
(11)
17%
(4)
0-27
28-264 days
1-4 years old
4%
(1)
21%
(5)
5-9 years old
10-14 years old
15-18 years old
7
3.5 Ethnicity Breakdown
Diagram 2 shows a breakdown of child deaths reported to CDOP in 2012-13 according
to ethnicity. 46% (11) of deaths were among the Black African/Caribbean/ Black British
group of the resident population.
During 2013-14, the Public Health Directorate will assist the CDOP with statistical
analysis of the local neonatal, infant and child mortality rates, using comparative and
statistically reliable methods. This will enable the borough to gain a better understanding
of any factors such as age, sex, ethnicity or location. This information will be included in
the Joint Strategic Needs Assessment (JSNA) and refreshed annually.
Diagram 2
Breakdown of child deaths according to
Ethnicity
8%
(2)
White British
34%
(8)
Mixed Ethnic Groups
Asian or Asian British
46%
(11)
8%
(2)
4%
(1)
Black / African /
Caribbean/ Black British
Other ethnic Groups
3.6 Sudden Unexpected Deaths in Infancy (SUDI)
Of the 24 deaths reported to CDOP this year, one involved Project Indigo the
Metropolitan Police Service response to SUDI. Whilst the cause of death retuned by the
Coroner is SUDI, the panel has not yet reviewed it to formally categorise it. See Point 6
below for further details.
4
Commentary on cases reviewed
This section will provide commentary on the cases reviewed and where modifiable
factors have been identified.
4.1 Number of meetings held
CDOP developed a Pre Review Group (PRG) meeting to look at all the cases, before
they are presented to the CDOP. The case is discussed and the meeting determine
whether there is sufficient information; propose a category of death and consider any
modifiable factors.
During 2012-13 CDOP met six times. The PRG also met in excess of six times to fully
consider the cases and any potential concerns. These increased number of meetings
were paramount to reviewing 46 cases that included six cases from 2010-11 and 27
cases from 2011-12.
8
At 31 March 2013, there were 10 child death reviews that were ongoing.
4.2 Number of reviews completed
46 child death reviews were completed by CDOP in 2012-13. This is significantly higher
than the reviews completed in previous years.
Table 4 gives a breakdown of the child deaths that were reviewed and the year the child
died.
Table 4
Number of child deaths
that occurred between 1
April 2010-11
6
Number of child deaths that
occurred between 1 April
2011-12
27
Number of child deaths
that occurred between 1
April 2012-13
13
Of the 46 child death reviews completed, 18 were identified as having modifiable
factors.
CDOP categorised the likely cause of death and recorded the event that caused the
death.
Table 5 below shows the highest number of deaths was among the perinatal/neonatal
event with 11 (24%). These deaths were largely due to prematurity with 6 identified as
having modifiable factors. 8 (17%) were among the trauma and other external factors.
These included Road Traffic Accidents, Fire and Choking. The three where insufficient
information has been categorised, these were due to deaths that occurred abroad.
8(17%) were among the chromosomal, genetic and congenital anomalies and no
modifiable factors were identified.
Table 5
Trauma and other
external factors
Malignancy
Acute medical or
surgical condition
Chronic medical
condition
Chromosomal, genetic
and congenital
anomalies
Perinatal/neonatal
event
Infection
Sudden unexpected,
unexplained death
Unknown category
TOTAL
Number of child
deaths with
modifiable factors
recorded under
this category of
deaths
Number of child
deaths with no
modifiable factors
recorded under
this category of
deaths
Number of child
deaths where there
was insufficient
information to
assess if there
were modifiable
factors
3
2
6
3
3
1
8
6
3
5
2
3
1
18
25
3
9
Table 6 shows a breakdown of the child deaths identified as having modifiable factors
and the year the child died.
Table 6
Number of child deaths with
modifiable factors that
occurred between 1 April
2010-11
5
Number of child deaths
with modifiable factors that
occurred between 1 April
2011-12
11
Number of child deaths
with modifiable factors
that occurred between 1
April 2012-13
2
Tables 7 and 8 show the categorisation of deaths where modifiable factors have been
identified and the event that caused the death.
Table 7
Category
Trauma and other external factors
Acute medical or surgical condition
Perinatal/neonatal event
Infection
Sudden unexpected, unexplained death
TOTAL
Number of child deaths
with modifiable factors
recorded under this
category of deaths
3
3
6
3
3
18
Table 8
Events
Neonatal death
Sudden unexpected death in infancy
Road traffic accident/collision
Fire and burns
Infection
Acute Bronchitis
Epilepsy
Sickle Cell Crisis
TOTAL
Number of child deaths
with modifiable factors
recorded under this
event
6
3
2
1
3
1
1
1
18
4.3 Neonatal Deaths
There were six neonatal deaths, where modifiable factors were identified (see tables 7
and 8 above). These deaths were classified as expected deaths however three Serious
Incident (SI) Reports were completed by Barking, Havering and Redbridge University
Hospitals NHS Trust (BHRUT). The SIs are monitored by NHSBD through their Clinical,
Quality Review Meeting.
4.4 Sudden Unexpected Death in Infancy (SUDIs)
There were four SUDIs reviewed by CDOP. Three were identified as having modifiable
10
factors. The issues identified were inappropriate feeding in a car seat by the road side;
no follow-up care plan for child with significant haemolytic disease with attending risk of
anaemia and prolonged jaundice; anti-viral treatment should have commenced earlier as
precautionary to herpes simplex.
4.5 Unexpected deaths
Of the 46 child death reviews, 20 (43%) were classified as unexpected deaths.
Table 9 gives a breakdown of the unexpected deaths according to the events classified
by CDOP. 12 were identified as having modifiable factors.
Table 9
Unexpected Deaths
Number of child
deaths with
modifiable factors
recorded under
this event
Known life limiting
condition
Sudden unexpected
death in infancy
Road traffic
accident/collision
Fire and burns
Other non-intentional
injury/accident/trauma
infection
Epilepsy
Sickle Cell Crisis
Acute Bronchitis
TOTAL
Number of child
deaths with no
modifiable
factors recorded
under this event
Number of
child deaths
where there
was
insufficient
information to
assess if there
were
modifiable
factors
1
3
1
2
1
1
1
2
1
3
1
1
1
4.6 Expected Deaths
Of the 46 reviews carried out, 26 related to expected deaths. 18 of these were to under
1 year olds with the majority classified as perinatal/neonatal deaths.
4.7 Time between the child’s death and completing the review
Table 10 below provides a breakdown of the child death reviews according to modifiable
factors and number of months.
Data analysed by Department for Education (DfE) suggests that reviews of child deaths
11
are likely to take longer if modifiable factors are identified. DfE says that nearly 40% of
deaths where modifiable factors were identified took more than 12 months to complete.6
Table 10
Under 6 months
Number of child deaths which were reviewed within the
following time periods (from the date of death to the date
the review was completed)
Number of child
Number of child
Number of child
deaths with
deaths with no deaths where there
modifiable factors modifiable factors
was insufficient
information to
assess if there
were modifiable
factors
9
1
6 or 7 months
1
3
8 or 9 months
2
2
10 or 11 months
4
4
12 months
Over one year
2
1
11
6
18
25
Unknown
TOTAL
5
3
Modifiable Factors and Recommendations to all cases reviewed between 2012-13
The modifiable factors identified relate to both unexpected and expected deaths with the
majority to unexpected deaths. Recommendations were made by CDOP some arising
from SIs and internal investigations. See Appendix 1 for details.
6
Actions taken following the reviews of child deaths
In 2012-13, as well as recommendations made to agencies, CDOP worked with
Children's Rights, Participation & Engagement to raise awareness of fire and road safety
during child safety week. CDOP also worked jointly on the safe sleep campaign to
SUDIs with Havering, Redbridge and Waltham Forest.
Project Indigo’s Draft SUDI – Analytical Report 20137 states that Barking and Dagenham
is among the priority boroughs as BD contribute to 48% of all SUDIs in London since
2005. In the East region, 61% of SUDIs occur in Barking and Dagenham, Hackney and
Newham combined.
Table 11 on the next page gives a breakdown of SUDIs in BD from 2005 to 20128. The
figures show on average two SUDIs a year. The SUDI recorded in 2012 has not yet
been reviewed by the Panel.
6
Department for Education Statistical Release 31 March 2013, page 7, para 7
Project Indigo’s Draft SUDI – Analytical Report 2013 has not yet received final sign off
8 These figures are recorded as per calendar year
7
12
Table 11
SUDIs from 2005-2012
SUDI
2005
2
2006
4
2007
2
2008
2009
4
2010
2011
4
2012
1
Total
17
Safe sleeping (including co-sleeping) continue to be a concern to panels, according to
DfE9. Other areas of concern are: language barriers and access to health services
especially emergency services; consanguinity, bereavement support to include support
offered to children following the death of a parent, carer or sibling; smoking and road
safety.
The majority of these concerns are being discussed by the north east London seven
borough CDOP. Redbridge and Waltham Forest have carried out some work relating to
consanguinity. Although, this is not currently an identified theme in BD, Redbridge and
Waltham Forest will share their findings with us at the next seven borough meeting in
September 2013.
7
9
Achievements

Developing the effectiveness and quality of the work of CDOP by increasing the
number of regular meetings and to include a Development Day within the yearly
planner.

Reviewing and closing a high number of open cases.

Revising the Terms of Reference to incorporate the roles and responsibilities of all
panel members

Working collaboratively with the 7 borough CDOPs within north east London to share
best practices and learning.

Involving bereaved parents and family members into the CDOP process by inviting
them to contribute to the process.
Department for Education, Statistical Release, page 9, para 5
13
8
Future Work Plan 2013-14

To consider how to develop the involvement of bereaved parents and family
members to the CDOP process.

To develop the recording of bereavement support offered to parents and family
members.

Work closely with the Public Health Directorate to identify areas to gain a better
understanding of any factors such as age, sex, ethnicity or location.

Develop the sharing of appropriate recommendations and learning to improve
practice and develop the effectiveness of CDOP.

Coroners have recently decided not to share Post Mortem reports with CDOPs
without the consent of parents. So that deaths can be reviewed thoroughly, CDOP
will be incorporating the request for consent within the initial letter that is sent to
families.

Identify joint training between Barking and Dagenham, Havering and Redbridge as
well as possible further development across the 7 boroughs of North east London.

Develop the CDOP process following the publication of Working Together 2013

Further develop the process following recommendations of CDOP

Further develop actions in response to emerging themes and modifiable factors
Report prepared by:
Roselyn Blackman
14
CDOP Manager
Appendix 1 – Modifiable Factors / Recommendations to child death reviews 201213
All SIs are monitored by NHSBD through their Clinical, Quality Review Meeting.
Un/expected
Modifiable Factors / Recommendations
Classification
UN
Road safety and the importance of parents being informed of
road safety in relation to young children
UN
Recommendations from BHRUT SI
Trust-wide observation competencies to include assessment of
pain.
To ensure that all patients waiting for treatment in majors are
clearly visible.
To ensure all Trust policies are adhered to, especially in Sickle
Cell and sepsis management.
Revaluate present pathway for 16-year-old adolescents with
Sickle Cell disease attending A&E.
To identify one specific monitor that is fully functional and can
be used during a resuscitation call on the ward.
To reduce the moves within the Trust, and conversely the
number of handovers, an adolescent unit could provide.
Specific care to patients who have complex medical needs.
UN
Clinical Assessment Treatment Services (CATS) to run
consultant only / nursing staff training (1/2 or full day) &
develop a rolling programme and re enact scenarios from A&E
and ward.
Improved provision of paediatric anaesthetists.
Employment of Paediatric Advanced Nurse Practitioners.
All paediatric staff to have Advanced Paediatric Life Support
training
Improved High Dependency Unit provision for children at
Queen’s Hospital
CATS to be contacted for support & advice earlier & to receive
appropriate information
UN
Recommendations from BHRUT SI
Feeding children with respiratory distress: It is important that a
written guideline is put in place re: indication of withholding oral
feed in children with respiratory distress. The guideline need to
be explicit about the volume and frequency of feed, route of
feed and when to recommence oral feed. It should also include
15
Un/expected
Modifiable Factors / Recommendations
Classification
a checklist to ensure proper placement of nasogastric tube
once it is inserted.
There is a need to develop a guideline re: indication of
commencing nasal continuous positive airway pressure (CPAP)
in young children with respiratory distress. This should include
exclusion criteria as well
It is a good practice to inform anaesthetic team at the beginning
of commencing any non invasive ventilation. These children are
potential candidate for ventilation and it would make things
easier for the anaesthetist to plan ahead.
Critical masses of nursing staff need to be trained in the use of
CPAP. This should be supplemented by regular ongoing
training. This may involve regular short term placement of staff
in the neonatal unit.
All the resuscitation trolleys (in A&E and ward) should contain
age appropriate intraosseous (IO) needles. IO with mechanical
device (EZ- IO) to be considered for its ease of use.
The information gathered in this investigation to be shared with
CATS so that learning points are shared and outcome of sick
children can be improved
The information gathered in this investigation to be shared with
the clinical team involved in this case so that learning points
are shared and outcomes for sick children can be improved
UN
Mum required early and timely intervention to support her
parental needs
Reducing the time between the assessment and strategy
meeting might have brought a different outcome.
This family required multi agency input, but there was no health
care plan
There was a period when child was non-compliant on
medication
Family support had been implemented but the Panel felt that
management and escalation of the case might have improved
outcomes.
There seemed to be a communication breakdown between
professionals.
16
Un/expected
Modifiable Factors / Recommendations
Classification
UN
Recommendation from internal investigation
BHRUT to have a medical discharge summary Standardised
Electronic Neonatal Database (SEND) summary in place
Discharge summary to identify newborns with acute and ongoing medical concerns, and give the care plan for primary
care and hospital outpatient if appropriate.
UN
UN
Clinical outcomes for babies to be included in mothers
postnatal notes for the attention of the community midwife
Awareness workshops for practitioners working with newborn
babies
Issues identified are
co-sleeping
poor parenting
Domestic Violence
Smoking
Late antenatal booking.
Issues identified
The GP had not been aware of the private fostering
arrangement
Health Visitor had not been aware of this child and therefore no
visits were made to this child
Clubbing (a deformity of the fingers and fingernails) was not
recorded in the GP notes. The Named GP, did say that unless
the clubbing was brought to the attention of any GP, this would
not be identified by the GP. Clubbing is a sign of respiratory
problems, however it is only looked for in adults.
The Practice Nurse was concerned that child had attended the
GP surgery without mother. This concern does not seem to
have been taken forward by the Practice Nurse. A new policy
has been created within the GP surgery where GPs are asked
to record the name of the person attending with the child.
The New Patient registration was not carried out in full. There
is a new registration policy being developed.
A Serious Investigation was not initiated until 54 days after the
death. SIs are now considered earlier, at rapid response stage,
within the CDOP process
Recommendations from BHRUT SI
To ensure that there is an anaesthetist with experience of
paediatrics who is comfortable looking after a critically ill child
at all times
To ensure that the dedicated area for critically ill children is
equipped at all times
To ensure that the Lead Consultant for Clinical Governance in
both Paediatrics and Neonates to be involved in SIs with the
support of the General Manager
17
Un/expected
Modifiable Factors / Recommendations
Classification
The post mortem reports to be sent to clinicians
To identify the primary care team for every child that comes to
A&E
To review the pathway for the care and management of
critically ill children
To ensure that clinical staff have the appropriate training to
manage a critically ill child
To provide training for clinical and administrative staff about the
SI process
UN
Issues identified
Poor parenting
Poor schooling attendance
Poor condition of house – very neglectful conditions that
resulted in a referral to children’s social care
UN
There was no fire guard present in the home
There should have been greater and ongoing involvement of
children’s social care by the preceding borough
Chair to present the case to preceding borough to determine
why an internal investigation was not carried out.
UN
Inappropriate feeding in a car seat
Should mum become pregnant again, mum should be booked
as high risk
Women with history of mental health should be referred to
perinatal mental health service
If mum becomes pregnant again, additional health visitor
support with parenting and feeding practices should be
provided. And, formally documented
UN
Issue identified
Mum should have received more support around her
communication abilities
EX
Histology showed mum was the carrier of herpes simplex.
CDOP agreed that BHRUT should have erred on the side of
safety by starting treatment with anti-virals earlier.
EX
Recommendations from BHRUT SI
All clinicians to be made aware of the importance of full
documentation in the antenatal period as decision made may
impact on plans of care later in the pregnancy / labour.
Audit of compliance against documentation standards for
18
Un/expected
Modifiable Factors / Recommendations
Classification
vaginal birth after caesarean (VBAC)
Audit of standards of documentation carried out by supervisors
of midwives.
Action plan in place to address any shortfall or areas of
concerns.
All midwives to undergo review of their documentation and
understanding of the requirements for documentation as part of
the supervisory review with their own supervisor
Documentation and record keeping to be part of the new
mandatory programme of training for the multi-disciplinary team
and also a major component of the induction programme for
midwives, nurses and doctors,
Review of current compliance with escalation policy to ensure
escalation is not just based on bed capacity but is also related
to workload and complexity and number of ‘high risk; cases.
Template to be designed to demonstrate hourly review of
capacity / workload and ability of labour ward to manage.
National Patient Safety Agency (NPSA) score card to be used
to keep record of 4 hourly capacity.
Matron for labour ward and lead obstetrician for labour ward to
review pathways of care for the use of the four bedded area on
the labour ward to include admission criteria and procedures
for ensuring there is regular and timely review from the
obstetric team and the Consultant ward round
The objectives should include interpretation of
cardiotocography (CTGs), documentation of assessment and
plans of care and documentation of communication with the
client.
Feedback to midwife from her supervisor of midwives to include
a review of notes and assessment of learning from the case
Audit of CTGs to be implemented with feedback to the
education team for inclusion in CTG training.
Audit and findings to be shared with Labour ward matron to
action with staff.
Report to be shared and discussion of findings at Serious
Incident Group meeting, ward based meetings, risk newsletter,
perinatal meetings, labour ward forum and doctors and midwife
training sessions.
Action plan to be monitored through the Maternity Quality and
Safety Committee.
19
Un/expected
Modifiable Factors / Recommendations
Classification
Meeting to be arranged with relevant senior staff in maternity
EX
Issues identified
Mum was a high risk pregnancy and presented to triage and
went home before being seen.
There should have been a follow up call from the midwife.
Nothing was recorded in the medical records to show that mum
was advised not to leave etc.
EX
Issues identified
An earlier emergency call / presentation to hospital might have
prevented the onset of this labour.
Mum required an interpreter which might have also been a
contributory factor
EX
Recommendations from Serious Incident – BHRUT
Policy and Community guideline should be updated to reflect
national guidelines.
A&E, Maternity and Neonatology should coalesce as a working
group to provide a complete perinatal service for pregnant
women and their babies.
A&E, Maternity and Neonatology medical/nursing/midwifery
staff should receive designated training in-line with NICE
guidance to manage neonatal jaundice process.
Active Trust-wide promotion and dissemination of the referral
process for all midwives to the duty neonatal registrar/the duty
paediatric registrar.
EX
Recommendations from Serious Incident - BHRUT
The Triage and Transition pathway at the time of the incident
failed to provide a safe and timely service.
There are education and training issues in relation to CTG
interpretation and expected actions, and in particular for
sinusoidal traces.
The need for good quality documentation should be reinforced;
staff falling below the required standards should undergo
additional training and should have audits of their
documentation undertaken to ensure improvement in
standards.
The Labour Ward Coordinator should be clear about her
sphere of responsibility and accountability.
Communication would be better served by use of a tool to
guide effective transfer of information.
The maternity service should work more closely with the
transfusion service to ensure that women receive appropriate
doses of anti-D immunoglobulin in an optimal timeframe.
20
Un/expected
Modifiable Factors / Recommendations
Classification
The process of escalation should be reviewed for when care or
service delivery is being impacted by acuity or staffing.
The neonatal service would benefit from a more
contemporaneous method of capturing events / interventions
during neonatal resuscitation.
The use of a scribe for emergencies (obstetric and emergency)
would improve information capture and documentation
Supervisor of Midwives review
21