Concern 1

• X was recruited as a locum registrar by the Hospital Trust without there appearing to have been any assessment of his skills and abilities or any supervision of him at the hospital. This was not an emergency appointment after, for example, a doctor calling in sick at the last minute. X gave evidence that the recruitment, assessment and supervision of locums is a national problem and that there is a need for a review on a national level. This raises concerns that there may be a risk to other lives both at this trust and at other trusts in the future.

Recommendation 1

• NHS England and the Royal College of Obstetricians and Gynaecologists consider a review at a national level into the recruitment, assessment and supervision of locum on obstetric and gynaecology wards together with the publication, if appropriate, of new guidelines. Particular emphasis should be 9 considered upon delineating the permitted scope of locums' activities before they are left responsible for out of hours care of women in labour.

Concern 2

• The current policy of the East Kent Trust states that it is the responsibility of the healthcare professional who will be supervising the locum to assure themselves of his/her competence. This did not happen in this case. There is at present no requirement for a locum to be assessed on a day shift by a consultant before being left in charge overnight. There is no clear direction that it is the responsibility of the assessing consultant to satisfy themselves of the locum's experience and capability. One specialist from outside the East Kent Trust, X, also stated that it would assist the assessing consultants to be able to see not only the locum's CV but also their references and any training records available.

Recommendation 2

• The East Kent Trust should consider taking action to ensure that there is a dedicated consultant responsible for reviewing the CVs and references of prospective new locums before they are appointed or employed. A record should be kept of the consultant concerned together with a copy of the consultant's written opinion. The East Kent Trust should also consider making the locum's CV, references and training records (where there are any) routinely available to all consultants with whom the locum will work. Wherever possible a locum should be assessed by a consultant upon a day shift before being left in charge overnight. It is also recommended that the East Kent Trust 10 should consider making it clear that it is the supervising consultant who is at all times responsible for ensuring that the locum working under their supervision is both competent and experienced for the role.

Concern 3

• X had worked two night time shifts at the QEQM before the night of Harry's birth. The extent to which there was any feedback from the consultants on call those two nights to X is unclear. She, erroneously, believed the East Kent Trust had employed X. There is no record of any written feedback. From the evidence of the medical director of the East Kent Trust it appears that the current locum recruitment policy is not being checked or audited. There is a potential for further risks to life arising from these shortfalls.

Recommendation 3

• Pending any possible review by NHS England and any new guidelines upon the assessment and recruitment of locum doctors it is recommended that the East Kent Trust consider taking action to ensure that consultants who have supervised a locum whether on a day or a night shift should provide written feedback upon the locum's competence and experience to be made available to the relevant HR team at the East Kent Trust and also to any other consultants who may be working with the locum in the future. The East Kent Trust should consider a review of its current procedures as to compliance with policies on the recruitment of new locums, including any new locum recruitment checklist, are being complied with. That review should include 11 consideration of whether there should be a regular audit of compliance. The East Kent Trust should also consider a review of its current procedures relating to the assessment and recruitment of locums to ensure that they meet all current professional guidelines. The East Kent Trust should also review the means by which locums have access to all their policies and procedures including the need for the escalation of care to the consultant, when necessary. There should be consideration of a computer sign in system so that there can be a check that the locum has in fact seen and read the policies.

Concern 4

• There is a risk to the life of both mothers and babies if there is a lack of clarity as to the processes or the need to take prompt action where it is necessitated in the event of an obstetric concern or emergency developing.

Recommendation 4

• There should be consideration of a review by the East Kent Trust of the obstetric policies, procedures and protocols which relate to the actions which are mandated by the East Kent Trust in the event of a pathological intrapartum CTG including, specifically, those actions which are required, and the relevant time frame, when the 'expedition of delivery' is called for.

Concern 5

• There appeared to be from the evidence given at the inquest substantial confusion amongst staff as to when a consultant should be called at night. The East Kent Trust now has some 70 hours a week consultant attendance on the wards. That leaves 14 hours a day when there is no consultant present. Staff, whether doctors, nurses or midwives should know the circumstances in which consultant help should be sought and should not feel inhibited from making their views known. If staff are unaware or unsure of when the consultant should be called that potentially poses a continuing risk to life.

Recommendation 5

• The East Kent Trust should consider a review the procedures in place to ensure staff understand the circumstances in which consultant attendance is required and, if necessary, deliver specific training upon this issue.

Concern 6

• The current contracts at the East Kent Trust permit consultants to live up to 30 minutes travel time from the hospital. This poses considerable problems and risks for night time emergencies.

Recommendation 6

• The East Kent Trust should consider research into any technological solutions which could be found to assist in, or ameliorate, the difficulties of on call consultants living some distance away from the hospital, for instance the use of video link technology or skype connections to the theatres and/or computer terminal readouts from home. 

Concern 7

• The evidence of raised substantial concerns about the quality of training and learning in respect of neonatal resuscitation at the East Kent Trust. His evidence was that it would be desirable for middle grade doctors to attend the ARNI course (the advanced resuscitation of the new born infant). He also recommended that there should be simulated drills in neo natal resuscitation.

Recommendation 7

• The East Kent Trust should consider a review of the current procedures for all relevant staff to attend regular drills and simulation training events covering neo natal resuscitation. The East Kent Trust should consider whether such training should be mandatory and that attendance at such courses is clearly recorded.

Concern 8

• Prior to Harry's death both X, a senior member of staff who had the care of Harry at the William Harvey Hospital, accepted that there were no opportunities for cross site working between QEQM and the William Harvey Hospital. Currently two out of eight middle grade doctors have had the opportunity to spend time at the William Harvey, which has a much higher specification neo natal unit. X described the lack of opportunities before Harry's death as ‘at best, very surprising'.

Recommendation 8

• The East Kent Trust should review the provision of cross site paediatric working so as to ensure that, where possible, within the next two years all middle grade doctors who aren't on the “run through specialist training programme in paediatrics” have spent a period of time at the level 3 William Harvey Hospital.

Concern 9

• The resuscitation of Harry was eventually carried out by X , the anaesthetist looking after X. His evidence was that leaving his own patient to help the paediatric team was an unusual action to take in the UK although he had often performed such actions in Nepal. Doctors at QEQM indicated that there was an informal policy that if a middle grade paediatrician found themselves in an emergency, they could seek help from their anaesthetic colleagues. It was unclear whether the anaesthetists were aware of this informal policy. This informal policy should be clarified, and guidance given because there is a risk, that in an emergency, it will be overlooked.

Recommendation 9

• The East Kent Trust should consider a review the circumstances in which anaesthetists are expected to attend and assist neonatal emergencies and to ensure that all relevant members of staff are aware of the policies.

Concern 10

• There appeared to be considerable confusion among members of staff as to which, if any, guidelines and policies affected them. While two senior members of staff, X (consultant), said that the East Kent Trust has systems in place to ensure knowledge of and compliance with Trust policies neither of them was able to say whether this was effective. Significant issues remain as to the knowledge of staff as to which guidelines govern their behaviour (this was also a finding of the Health and Safety Investigation Board in 2019). Such confusion or lack of knowledge increases the risk of future deaths.

Recommendation 10

• The East Kent Trust should consider a review of obstetric and paediatric staff's awareness of the governing clinical and operational guidance. The East Kent Trust should also consider keeping a register of when and if every member of staff signed off the relevant guidelines as read and understood. This could take place, for instance, at formal training sessions within the unit.

Concern 11

• There was a lack of knowledge within the paediatric team of guidelines issued by the Department of Women's Health. The evidence from the East Kent Trust doctors was that the guidelines issued by the department directed to 'all maternity and neonatal staff who may be involved with the immediate care and support of a collapsed neonate' would not have been known to the paediatric team at the relevant time. Even senior clinicians, such as X, were not aware of the relevant guidelines.

Recommendation 11

• The East Kent Trust should consider taking action to ensure that the current neonatal resuscitation guidelines are brought to the attention of the neonatology and paediatric teams at the QEQM. Guidelines issued by one department, but which are relevant to staff in a different department should be disseminated and understood by those staff. This could take place during senior management meetings, organised cross department training or electronically with the recipient confirming receipt, reading and understanding of the material.

Concern 12

• The placenta of Harry was not retained. Examination of the placenta will in some circumstances assist in cases of severe foetal distress. The Royal College of Pathologists states that it is 'essential' for the placenta to be sent for examination in cases of severe foetal distress requiring admission to a neo natal unit.

Recommendation 12

• The East Kent Trust should consider amending its neonatal guidelines to reflect the mandatory nature of the Royal College guidelines to ensure that the placenta is always kept and sent for histology and a record should be kept of each and every such instance.

Concern 13

• The standard of record keeping on the obstetric unit was substantially sub-standard. The quality of the note taking and records is of considerable importance to new staff taking over responsibility for mother and baby. Without there being clear accurate records there is a risk of further mistakes being made leading, at the worst, to the risk of death. An example of this in Harry's case is that the record of the syntocinin prescribed to X over a long period of time is inconsistent with the evidence of the midwives and the registrar who gave it to her.

Recommendation 13

• The East Kent Trust should consider an audit of the quality of record keeping and documentation and consider whether further training is required so that staff understand the crucial importance of clear and accurate record keeping.

Concern 14

• There are no current records kept by consultants who are telephoned at home for advice. In this case there was a dispute about the number of calls made to X and as to the content of these calls. The advice given and the actions taken as a result are important for the preservation of life.

Recommendation 14

• The East Kent Trust should consider whether consultants should be asked to keep full records of advice given to junior doctors over the telephone and to time and date them.

Concern 15

• The East Kent Trust should consider a review as to the use or otherwise of a resuscitation pro forma. A pro forma has since Harry's death been adopted by the East Kent Trust which, on the evidence of X, has improved the oversight of neo natal training and governance. It is not clear whether that pro forma is being audited or logged, or what actions are being done to ensure its completion and preservation.

Recommendation 15

• The East Kent Trust should consider keeping clear records of the use of the pro forma and checking the efficiency of it. The East Kent Trust should also consider whether further training is necessary to ensure the best use of it to prevent further deaths occurring.

Concern 16

• In order to try to prevent future deaths it is important that there are clear records and statements made when a death occurs so that lessons can be learnt. In this instance many of the statements were very scanty in their content and some were made a long time after the event. In some instances, staff had to make statements from memory without the advantage of seeing the medical notes. Contemporaneous (or as near as possible) notes are also very much in the interests of the staff involved so that they can give clear accounts of their actions and reasons for them if required to do so at a later date.

Recommendation 16

• Where there has been a serious incident staff should be asked to make statements as soon as possible after the event. They should be provided with the medical records to do so. The statements should then be timed and dated and kept in a secure place by a third party.

Concern 17

• The child death notification form was incorrectly completed in that Harry's death was recorded as 'expected'. No notification was made to the Coroner. No details were filled in on the notification form giving any detail of the problems leading to Harry's death. As a result, the Child Death Overview Panel would have been unaware of the problems encountered and could not have shared learning to prevent other such deaths occurring. I make no recommendation in respect of the lack of notification to the Coroner as I am aware that the Senior Coroner has already dealt with this.

Recommendation 17

• The East Kent Trust should consider a review of its policies so that all staff members who fill in Child Death Notification forms are aware of what to enter into the form and of the details required. All such forms should be logged and audited, including those since Harry's death.

Concern 18

• The MBRRACE form in respect of Harry Richford was inaccurate in a number of important areas. The form is important to provide robust national data to support the delivery of safe, high quality maternal and new born care as well as identifying errors and faults, if any, where there has been a maternal or infant death so that future deaths can be avoided.

Recommendation 18

• The East Kent Trust should consider a review of all MBRRACE forms filled in since Harry's death were accurately completed and reported. The East Kent Trust should also consider whether it would be advisable to have a second person checking and signing off an MBRRACE form before its submission.

Concern 19

• Important independent reports do not appear to have been shared within the East Kent Trust's staff, for instance the HSIB report into Harry's death appeared during the inquest to be unknown to a number of the staff.

Recommendation 19

• The East Kent Trust should consider a review of its policies in respect of the sharing of important investigations amongst all relevant staff so that important learning takes place to prevent any future deaths.

Delays in defibrillation

The reports in question relate to the deaths of Najeeb Katende in 2016 and Mitica Marin in 2019.[3] In both cases, an issue had occurred when using the LP15 defibrillator, which had been started in ‘manual’ rather than ‘automatic’ mode. This resulted in the paramedic not initially realising the patient had a shockable heart rhythm and led to a delay before the first shock was administered. If the defibrillator had initially been in ‘automatic’ mode it would have detected a rhythm and prompted the paramedic to shock the patient.

In the coroner’s report into the death of Mitica Marin, it was noted that LAS had carried out a review of cases of delayed defibrillation with the LP15 and recognised that this specific machine “defaults to manual mode requiring the user to switch to automatic mode before use”.[4] Garrett Emmerson, LAS Chief Executive, noted that they were now taking a series of actions to address this, “including putting warning stickers on the defibrillators and staff refresher training on how to use the machines”.[1]

Preventing future deaths

While this case focuses a specific safety in use issue concerning the LP15 defibrillator, it also serves to highlight the broader issue we have previously raised at Patient Safety Learning; failure to harness learning from PFD reports. We believe that by learning from PFD reports, patient safety can be improved and the reports can achieve their aim of preventing future deaths.[5]

One of our concerns in this regard is that learnings from PFD reports may be applicable beyond the organisation, however at present there appears to be no clear system of sharing learning more widely. We are pleased that LAS has identified this safety issue, however it is vital that this information is now widely shared so others can also take action to manage the risks to patients. If the concerns identified in PFD reports remain in silos, there is a danger that this could reoccur in a different trust.

At Patient Safety Learning, we believe there are a number of actions which could be taken to help address the current gaps in the system. Please refer to our previous blog on Learning from PFD reports to see these actions in detail.

References

1.    HSJ, Patient deaths prompt ambulance chiefs to look for alternative defibrillators, 10 August 2020. 

2.    The Coroners (Investigations) Regulations 2013, SI 2013/1629.

3.    Edwin Buckett, Prevention of Future Deaths Report – Najeeb Katende, 21 April 2017.

4.    Graeme Irvin, Prevention of Future Deaths Report – Mitica Marin, 12 March 2020.

5.    Patient Safety Learning, Learning from Prevention of Future Deaths reports, 25 February 2020.

1. The NHS 111 telephone triage service uses the NHS Pathways computer system to triage patients via pre-determined question/answer based algorithms. The pre-determined questions are the same whether the caller is an adult or a child. Alex struggled to comprehend some of the medical terminology used during these calls. Call handlers are not permitted to deviate from the prescribed wording of the pre-determined questions, and this created confusion and inconsistency in the patient’s answers. Consideration should be given as to how young and/or vulnerable patients can be assisted to provide accurate information about their symptoms.
2. The NHS Pathways algorithm for triaging vomiting and diarrhoea symptoms is unclear as patients may fail to understand what is meant by ‘soil’ or ‘coffee ground’ vomit. Consideration should be given to how this important diagnostic feature can be explored during telephone triage, especially when the patient is young and/or vulnerable.
3. The NHS 111 telephone triage service provides an electronic copy of the patient triage notes to the patient’s GP within minutes of the call ending. There was a delay of 7 days in the GP surgery uploading the 111 triage document to Alex’s patient record. This prevented Alex’s GP from reviewing the triage note prior to his consultation with the patient. There is no guidance as to expected practise with regards to the timely updating of electronic patient records, and as a result delays are all too frequent.
4. Adults presenting to their GP or Emergency Department with abdominal symptoms receive a lipase and/or amylase blood test as part of the standard package of blood testing. The levels of each of these enzymes can be used to diagnose pancreatitis. Patients under the age of 18 years are not offered this testing as standard, on the basis that pancreatitis is rare in paediatric patients. The coroner heard anecdotal evidence of some doctors at Kingsmill Hospital now add this test to the standard admission bloods for older teenage patients who present with non-specific abdominal symptoms but the NICE guidance (September 2018) is not explicit in this regard. Consideration ought to be given to a national approach for lipase/amylase testing in young people with relevant symptoms.
5. Patients who make an unscheduled return to the Emergency Department within 72 hours of discharge are required to have a review undertaken by an ED Consultant, or a ST4 trainee or above in the absence of a Consultant on the ‘shop floor’: RCEM Guidance June 2016. Some hospitals will admit returning paediatric patients for observations but practise seems to vary doctor-to-doctor and across Trusts. Consideration ought to be given to a national approach.

Without changes in the NHS Pathway the 111 call handlers will not be adequately assisted by the Pathways to recognise the acutely unwell child, in particular:

1. at the time of the conclusion of the inquest, there was no question within the NHS Pathways questionnaire concerning cold hands and feet for children aged over five
2. at the time of the conclusion of the inquest, the question regarding green vomit, asked in respect to children over five, had an inappropriately high threshold (that is required severe pain for more than four hours before the question was engaged) and would not have been activated in Sebastian's case
3. there is no indication that NHS Pathways/NHS Digital have reviewed the support arrangements for non-clinically qualified advisers to refer unusual cases to clinically qualified staff
4. at the time of the conclusion of the inquest, NHS Pathways' questions did not allow meaningful assessment of pain in a child; that is to say questions about severity of pain and the ability of a child to communicate such pain should be reviewed at national governance level.

Questions:

• Have you got a system for checking call bells where you work?
• Are the call bells always in reach of the patient?

There is a statutory duty for coroners to issue a PFD report to any person or organisation where, in the coroner’s opinion, action should be taken to prevent future deaths. These reports are made publicly available on the Coroners Tribunals and Judiciary website with the organisations involved having a duty to respond within 56 days.

When serious incidents occur in healthcare that result in the death of a patient, PFD reports play a key role in identifying what went wrong and the actions needed to prevent this reoccurring. These crucial insights may often be applicable beyond the organisation in which this took place and provide a point of wider system learning.

Implementing actions and sharing learning

While these reports provide a wealth of information, the key challenge is ensuring that we utilise these to their full extent to improve patient safety and care. At Patient Safety Learning while we recognise the important role these reports have to play, we have some concerns about how they are currently acted on.

Implementing actions

When actions are requested by the coroner, it is not clear under the current system whether there is a structured process, either at a national or individual organisation level, for monitoring the actions implemented in response to the PFD report.

There is also an open question about who is held accountable if the actions requested are not fully implemented, or if the response taken is ineffective. It is difficult to assess how healthcare providers go about this as there appears to be no specific system of monitoring this at a national level.

Sharing learning

As noted earlier, often the learnings from PFD reports may be applicable beyond the organisation involved. However, at present there appears to be no clear system of sharing these outcomes more widely. Although these reports are published online, they are not in an easily searchable or shareable format and it is difficult to draw out common themes, actions and responses.

Furthermore, it is not clear whether NHS England and NHS Improvement undertake any central trend analysis or review to draw out common themes that may be applicable to all organisations, in the same way that the Healthcare Safety Investigation Branch does when it publishes its investigation reports.

What do we want to see?

We have recently written to the Chief Coroner, Judge Mark Lucraft QC, to raise these issues. We have also drawn this to the attention of Dr Alan Fletcher, the National Medical Examiner. As the new National Medical Examiner system is currently being rolled out across England and Wales, their role in ‘ensuring proper scrutiny of all non-coronial deaths’ will be complementary to the current PFD system. We feel it is important that coroners and medical examiners take a consistent approach to reporting and sharing learnings as widely as possible.

When we receive responses, we will take this up directly with NHS England and NHS Improvement, and other national bodies with responsibility for patient safety, along with our ideas of actions that we feel could help to address the current gaps in the system:

Implementing actions

1) Analyse reports – Sustainability and transformation partnerships (STPs)/Integrated Care Systems (ICSs) to carry out annual thematic reviews of all PFD reports, Serious Incident (SI) reports and associated safety action plans. These plans can inform future commissioning, safety action plans and Care Quality Commission oversight.

2) National oversight – put in place a clear system of national oversight.

Shared learning

3) Increase transparency – make all PFD reports, SI reports and their associated safety action plans available in the public domain.

4) Improve accessibility – create a central repository for all PFD reports, SI reports and associated safety action plans in one database searchable by actions and themes.

5) Standards – put in place patient safety standards for each STP and ICS, with requirements on individual trusts, primary care networks and service providers to share learning from these reports.

6) Publish an annual report – on PFD reports and SI reports including themes for learning and action.

• Which deaths are reported to the coroner
• What happens next after a death is reported
• About identifying the body
• Coroner liaison officers
• Post mortem examinations
• Post mortem results
• Returning the body
• Funeral arrangements
• Inquests