HSIB: Recognition of the acutely ill infant (9 December 2021)

Summary

The purpose of this investigation by the Healthcare Safety Investigation Branch (HSIB) is to help improve patient safety in relation to recognition of the acutely ill infant and child, recognising the difficulty in distinguishing between simple viral illnesses and life-threatening bacterial infections in very young patients.

This Healthcare Safety Investigation Branch investigation reviewed the case of Mohammad, a baby who had become unwell and was taken to an emergency department by ambulance following a call to NHS 111. He arrived at 8.04pm and was considered to have a mild viral illness, subsequently being transferred to a paediatric observational ward, and discharged at 11.45pm with a diagnosis of likely bronchiolitis.

At approximately 3.40am his mother contacted the ward as his condition worsened, which resulted in a 999 call. The ambulance crew did not consider that Mohammad was seriously ill so did not conduct a ‘blue light’ emergency transfer to hospital. Mohammad was admitted to the emergency department at approximately 4.40am and suffered a respiratory and then cardiac arrest at 5:28am, with attempts to resuscitate unsuccessful and stopped at 6:10am. Mohammad died of septicaemia caused by meningococcus (serogroup B) bacteria.

Content

Findings

Findings of this investigation included:

• The existing systems for triage do not always take into account the colour of a patient’s skin. This may influence a healthcare professional’s assessment of an infant’s/child’s physical signs.
• Staffing standards that relate to the treatment of children in emergency departments cannot always be met due to workforce challenges, particularly in hospitals without a dedicated paediatric emergency department.
• Sometimes parents describe feeling powerless when trying to articulate their concerns for their child. Some healthcare professionals do not always consider or listen to what parents are telling them.
• The Association of Ambulance Chief Executives are not currently involved in the ongoing national work to develop early warning scores for infants and children.
• Undergraduate training for paramedics on the identification of sick infants/children is variable across England.
• There is inconsistency across English ambulance services in training for ambulance personnel, including paramedics and non-registered clinicians, on the identification of sick infants/children.

Recommendations

The report makes the following safety recommendations:

• HSIB recommends that the Chair of the NHS System-wide Paediatric Observations Tracking (SPOT) Programme ensures that the Association of Ambulance Chief Executives, community NHS 111 providers and primary care services are integral members of the NHS SPOT Programme.
• HSIB recommends that NHSX develops national standards describing the electronic deployment of the NHS System-wide Paediatric Observations Tracking (SPOT) e-PEWS (the digital version of the Paediatric Early Warning Score tool), in collaboration with the NHS England and NHS Improvement SPOT Programme. This should include specifications for data capture, calculation of the score and escalation status, and also the display of the information and connectivity with other digital systems.
• HSIB recommends that the Chair of the NHS System-wide Paediatric Observations Tracking (SPOT) Programme ensures that any resources produced include examples of children and young people with non-white skin showing signs of serious illness.
• HSIB recommends that the Association of Ambulance Chief Executives works together with the ambulance services to share best practice in relation to paediatric training, education resources, frequency and types of training, and that it collates and shares areas of best practice.
• HSIB recommends that the College of Paramedics works with partners and higher education providers to develop, agree and implement standards for paediatric education for the future ambulance service workforce.

Response from Patient Safety Learning

Patient Safety Learning welcomes the publication of this new report by HSIB looking at ways to improve patient safety in relation to recognition of the acutely ill infant and child. Our reflections on this report are as follows:

Increased collaboration within the NHS SPOT Programme

We welcome HSIB’s recommendation that the NHS SPOT Programme should ensure it includes involvement from the Association of Ambulance Chief Executives, community NHS 111 providers and primary care services. The tragic circumstances of Mohammad’s death clearly emphasise the important role that each of these different services can play in the process of recognising life-threatening bacterial infections in very young patients.

Health inequalities

This investigation specifically draws attention to how existing systems for triage in primary and secondary care are not always considering the colour of a young patient’s skin, noting the impact this may have on a healthcare professionals’ assessment of physical signs. The report indicates that the importance of considering how symptoms and signs can present differently on dark skin has been highlighted in Mind the Gap: A handbook of clinical signs in Black and Brown skin. They also refer to the ongoing work of the Skin Deep Project, which aims to develop a free, open-access bank of high-quality photographs of medical conditions in a range of skin tones for use by both healthcare professionals and the public.

We welcome HSIB’s specific recommendation that the SPOT programme should seek to ensure its resources include examples of children and young people with non-white skin showing signs of serious illness. We know however that safety issues faced by patients due to the colour of their skin are not limited to these specific cases.

In line with the ambition set out in the NHS Long Term Plan to take a more concerted and systematic approach to “reducing health inequalities and addressing unwarranted variation in care”, we believe this should be a priority issue for the NHS National Patient Safety Team. We would like to see them working together with the Dr Bola Owolabi, Director – Health Inequalities at NHS England and NHS Improvement, to scope a potential programme of work in this area.

Listening to parents

The report highlights communication concerns from Mohammad’s parents, noting “the family’s perception is that they trusted what staff were telling them but that they were ultimately not listened to”. This remains a recurring problem in healthcare and emerges time and again in patient safety failings. Too often concerns raised by patients and family members are not acted on and, when harm occurs, they are left out of the investigation process.

In our report, A Blueprint for Action, we set out what we believe is needed to progress towards a patient-safe future, identifying six foundations of safe care. Patient engagement is one of those six foundations. In this, we outline how patients should be engaged for safety at the point of care, if things go wrong, in improving services, advocating for changes and in holding the system to account.

The value of early warning scores

The report highlights that research shows that existing early warning scores are not sensitive or specific enough to help health professionals to distinguish between a seriously unwell infant/child and one with a mild viral illness. It states that “changes in vital signs (for example temperature, heart rate and respiratory rate) may be predictors of deterioration in an infant or child but they may also simply reflect that a child is unwell but not at significant risk”.

We find it surprising therefore that there is not a reflection or recommendation on the need to support clinicians in their assessment of deteriorating patients, such as the further development of early warning scores.

Review of ambulance service training

The report notes the following safety observation:

“It may be beneficial if the 10 English ambulance services review and assess their paediatric training provision and report this assessment to their trust board.”

HSIB explains this observation is intended to “identify all clinical staff working in the ambulance service that have accessed ‘Spotting the sick child’ or equivalent training as an education resource and find out how often it has been accessed, and to highlight any gaps in training needs for recognition of the acutely ill infant/child”.

It is our view that it would be preferable for this to be a specifically cited safety recommendation for implementation and response.