Central and North West London NHS Foundation Trust
NHS / Health Body
Action Taken
The Trust has taken action to improve staff training in emergency response, including additional in-situ simulation sessions and building a simulation room. Learning from simulations is shared via team meetings and presented to the Resuscitation and Deteriorating Patient Committee. (AI summary)
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Dear Assistant Coroner Furniss,
Regulation 28: Report to prevent future deaths in relation to David Siirak
I am responding to the Regulation 28 Report issued on 7 March 2024 following the inquest into the death of Mr David Siirak on 4 March 2020. The inquest concluded on 7 March 2024.
Central and North West London NHS Foundation Trust (CNWL) deeply regrets the death of Mr. Siirak and the distress this has caused his family.
We accept the findings of the jury and have evaluated our response to the tragic death of Mr Siirak in light of the findings.
Matter of Concern
Mr Siirak was discovered in his room, having been assaulted, at 1647 hours on 1 March 2020. The crash team, led by , arrived at 1703 hours. The evidence was that between those times (until took charge at
1703) the response of ward staff to the incident was "chaotic" and "panicking" (as was acknowledged by the staff).
The evidence was that various members of your staff had never previously been involved in a real or simulated emergency. By "simulated emergency", I mean an unexpected dummy run on the ward, as opposed to training in the calm confines of a planned day.
One member of staff told the court that she had never been involved in an unexpected simulated emergency in the 14 years of working on the ward prior to 1 March 2020, nor in the 4 years since.
The jury found that "there was a clear failure to provide the adequate training in simulation exercises to effectively manage situations like the one that occurred on 1st March 2020."
It was equally clear on the evidence that members of staff have still not undergone unexpected simulation training.
I have addressed the concerns below :
Resuscitation training: In November 2022, the Trust updated its resuscitation training to the Nationally accredited RCUK Level 3 Resuscitation training also known as Immediate Life Support (ILS). It is a course where to be successful the participants need to successfully demonstrate the skills required to resuscitate a patient. Providing assurance to both the individual and the Trust. All participants are involved in multiple resuscitation simulations, all of which have been developed from incidents that have occurred within the Trust. All registered substantive Nurses and Doctors who work on inpatient areas are required to attend this course annually. The Trust monitors ILS training compliance in a range of groups, Committees and also at Board level. Through this monitoring we obtain assurance that all relevant staff have undertaken ILS training and simulation exercises. All Staff who were present during this incident, who still work at the trust, have now successfully passed and had experience of Resuscitation simulation. Training for temporary staff who work at CNWL is provided in line with an agreed training matrix as set out by Skills for Health. This standard means that all temporary staff who work within the Trust meet the agreed training standards for resuscitation.
Insitu simulation: This has been developed alongside a Trust-wide insitu Simulation education programme and compliments the training programme outlined above. This programme was launched and led by the head of Adult Education at CNWL in 2022. The Trust-wide programme covers many areas, with resuscitation simulation being one of those areas. This uses a unified approach to planning, running, debriefing and recording each simulation. The Resuscitation team has a suite of simulation’s developed from previous incident that have occurred across the trust.
Everyone involved in delivering and facilitating simulation has attended training provided by Milton Keynes University in 2022 and 2023, and local update training is planned for 2024. Since the launch of the programme over 100 insitu resuscitation simulations have been carried out across the trust, with 79 having occurred in the last year, one of these has occurred on Frays ward, including five members of staff.
As Frays ward sits on the Hillingdon Hospital site, and is covered by the Hillingdon Hospital Resuscitation team, they also provide insitu simulation and as a result an additional insitu simulation session has taken place.
The date and content of the insitu simulation is discussed with the Ward Manager or Matron, areas and type of resuscitation is discussed together with a date to occur
e.g. ligature, choking etc. Staff to attend is determined locally by the Ward Manager and Matron. The simulation is then run either as an unannounced or planned exercise. The team runs equal number of both.
Ward Managers and Matrons share learning from local insitu simulations with the wider team via team meetings and share additional learning across the local service via their Local Care Quality Group meetings.
Reports on simulations run, together with lessons learnt and follow on actions are also presented twice yearly to the Resuscitation and Deteriorating Patient Committee chaired by the Deputy Chief Medical Officer of the Trust.
Over the next 12 months, a rolling programme of insitu simulations is scheduled for every inpatient ward area, with additional sessions planned for areas identifying a greater need. Areas which may be considered as requiring additional input will include teams that have been involved in a recent resuscitation event and incident reviews.
The Trust is also currently building a simulation room, where staff identified as having a need to refresh can attend for planned sessions.
Thank you for raising your concerns. I hope that the content of this letter provides sufficient assurance that CNWL take the concerns raised seriously, has taken action following the death of Mr Siirak and has accepted the points raised and continues to work to improve the service we provide. Should you have any questions or concerns or comments, please do not hesitate to contact me directly.
Regulation 28: Report to prevent future deaths in relation to David Siirak
I am responding to the Regulation 28 Report issued on 7 March 2024 following the inquest into the death of Mr David Siirak on 4 March 2020. The inquest concluded on 7 March 2024.
Central and North West London NHS Foundation Trust (CNWL) deeply regrets the death of Mr. Siirak and the distress this has caused his family.
We accept the findings of the jury and have evaluated our response to the tragic death of Mr Siirak in light of the findings.
Matter of Concern
Mr Siirak was discovered in his room, having been assaulted, at 1647 hours on 1 March 2020. The crash team, led by , arrived at 1703 hours. The evidence was that between those times (until took charge at
1703) the response of ward staff to the incident was "chaotic" and "panicking" (as was acknowledged by the staff).
The evidence was that various members of your staff had never previously been involved in a real or simulated emergency. By "simulated emergency", I mean an unexpected dummy run on the ward, as opposed to training in the calm confines of a planned day.
One member of staff told the court that she had never been involved in an unexpected simulated emergency in the 14 years of working on the ward prior to 1 March 2020, nor in the 4 years since.
The jury found that "there was a clear failure to provide the adequate training in simulation exercises to effectively manage situations like the one that occurred on 1st March 2020."
It was equally clear on the evidence that members of staff have still not undergone unexpected simulation training.
I have addressed the concerns below :
Resuscitation training: In November 2022, the Trust updated its resuscitation training to the Nationally accredited RCUK Level 3 Resuscitation training also known as Immediate Life Support (ILS). It is a course where to be successful the participants need to successfully demonstrate the skills required to resuscitate a patient. Providing assurance to both the individual and the Trust. All participants are involved in multiple resuscitation simulations, all of which have been developed from incidents that have occurred within the Trust. All registered substantive Nurses and Doctors who work on inpatient areas are required to attend this course annually. The Trust monitors ILS training compliance in a range of groups, Committees and also at Board level. Through this monitoring we obtain assurance that all relevant staff have undertaken ILS training and simulation exercises. All Staff who were present during this incident, who still work at the trust, have now successfully passed and had experience of Resuscitation simulation. Training for temporary staff who work at CNWL is provided in line with an agreed training matrix as set out by Skills for Health. This standard means that all temporary staff who work within the Trust meet the agreed training standards for resuscitation.
Insitu simulation: This has been developed alongside a Trust-wide insitu Simulation education programme and compliments the training programme outlined above. This programme was launched and led by the head of Adult Education at CNWL in 2022. The Trust-wide programme covers many areas, with resuscitation simulation being one of those areas. This uses a unified approach to planning, running, debriefing and recording each simulation. The Resuscitation team has a suite of simulation’s developed from previous incident that have occurred across the trust.
Everyone involved in delivering and facilitating simulation has attended training provided by Milton Keynes University in 2022 and 2023, and local update training is planned for 2024. Since the launch of the programme over 100 insitu resuscitation simulations have been carried out across the trust, with 79 having occurred in the last year, one of these has occurred on Frays ward, including five members of staff.
As Frays ward sits on the Hillingdon Hospital site, and is covered by the Hillingdon Hospital Resuscitation team, they also provide insitu simulation and as a result an additional insitu simulation session has taken place.
The date and content of the insitu simulation is discussed with the Ward Manager or Matron, areas and type of resuscitation is discussed together with a date to occur
e.g. ligature, choking etc. Staff to attend is determined locally by the Ward Manager and Matron. The simulation is then run either as an unannounced or planned exercise. The team runs equal number of both.
Ward Managers and Matrons share learning from local insitu simulations with the wider team via team meetings and share additional learning across the local service via their Local Care Quality Group meetings.
Reports on simulations run, together with lessons learnt and follow on actions are also presented twice yearly to the Resuscitation and Deteriorating Patient Committee chaired by the Deputy Chief Medical Officer of the Trust.
Over the next 12 months, a rolling programme of insitu simulations is scheduled for every inpatient ward area, with additional sessions planned for areas identifying a greater need. Areas which may be considered as requiring additional input will include teams that have been involved in a recent resuscitation event and incident reviews.
The Trust is also currently building a simulation room, where staff identified as having a need to refresh can attend for planned sessions.
Thank you for raising your concerns. I hope that the content of this letter provides sufficient assurance that CNWL take the concerns raised seriously, has taken action following the death of Mr Siirak and has accepted the points raised and continues to work to improve the service we provide. Should you have any questions or concerns or comments, please do not hesitate to contact me directly.