Riya Hirani

Dear Coroner, RE: Inquest of Riya Hirani 14 September 2023 We write further to the inquest touching upon the death of Riya Hirani, which took place on 14 September 2023. At the conclusion of this inquest, the Coroner issued a Prevention of Future Deaths (PFD) report. The PFD noted that the Coroner had concerns that the junior doctor did not appreciate the severity of Riya’s condition and in essence that incorrect medical treatment was provided. The PFD has been sent to the Trust, as the Coroner believes that the Trust has power to take actions to prevent further deaths. We have provided narrative on the actions already undertaken and future actions as detailed below. Point of care testing Point of care testing is now fully operational within our emergency pathway for measuring and assessing Streptococcus A and respiratory illness in children. New standard operating procedure A new locally devised standard operating procedure (SOP) entitled ‘Paediatric Medical Examination’ is in the development stage and this document details the escalation process for advice and support with clinical concerns both in and out of standard working hours for healthcare professionals when working with deteriorating children both in the emergency pathway and on the Paediatric inpatient wards. As part of this SOP, we are also introducing a SBAR model [which stands for Situation, Background, Assessment, Recommendation], this will help to create an understanding of a shared model around patient handovers and situations requiring escalation or critical

Trust headquarters: Find us online Northwick Park Hospital, Watford Road, HA1 3UJ

+44 (0)20 8864 3232

exchange of information such as sepsis. This SOP also incorporates and supports the principles of Martha’s Law and the ability for families and health professionals to seek second and more senior opinions when remaining concerned after a clinical review. Additionally, the SOP now supports the need for discussion to the next level of seniority and a mandated Face-to-Face clinical review of all children seen within the emergency pathways prior to discharge. The SOP will be due for completion by the end of December 2023. This is currently in draft form and has been shared across speciality, with senior trust clinicians for input and socialisation. We would value input from Riya’s family into the finalised version of the SOP prior to formal ratification and would hope to co-produce the final document with them, but acknowledge this may understandably be difficult for them. Once finalised, the SOP will follow the Trusts governance process for formal ratification and will be shared widely with staff through local departmental, divisional and trust governance meetings. After ratification, the document will be available on the Trust intranet for ease of access and displayed in clinical environments. Our communications department will be approached to share on the trust bulletin and screen savers. As an interim measure pending completion of the SOP all clinicians have been advised through multi professional meetings and via email communication that if a caregiver raises concerns following clinical review the clinician should have a low threshold for seeking senior review. We would be happy to provide the coroner with an update and a copy of the ratified SOP once this has been completed. To provide assurance that this process has been embedded a clinical audit will be undertaken six months after its launch, and at annual intervals thereafter. Nationally approved Paediatric Early Warning System The Trust also confirms that the newly launched Nationally approved Paediatric Early Warning System observation and escalation charts, known as PEWS, will be implemented as per the national requirement. This tool is to support clinicians when assessing children who are acutely unwell or at risk or rapid deterioration and will enable staff to quickly be able to identify deterioration of the child, escalate care, and act on parental concerns. The PEWS charts have been collaboratively developed by clinical teams across England to standardise the approach of tracking the deterioration of children in hospital. Multi-disciplinary working In regard to the care of children with complex medical needs the Paediatric service has a weekly meeting where children with complex medical needs are discussed, and further guidance can be sought from other specialties where needed. The meeting is chaired by

Trust headquarters: Find us online Northwick Park Hospital, Watford Road, HA1 3UJ

+44 (0)20 8864 3232

the Clinical Director of their designated deputy, and attended by the multi-disciplinary team and other clinical specialist disciplines when needed and a plan of care is agreed. The MDT includes a minimum of 6 paediatric consultants, junior doctors and nursing representation. In instances where a patient is acutely unwell and earlier input is required this occurs dynamically, rather than at the weekly meeting. Additionally, the Trust holds a monthly Deteriorating Patients Group. This is chaired by the Trust Medical Director and is an organisational Trust platform to discuss deteriorating patients, where cases are reviewed, and learning is embedded into future practices. This meeting is attended by Director level clinical staff from all clinical specialties and subgroups to ensure collaborative and robust oversight. This meeting is formally minuted, develops actions with named lead professionals and influences Trust policies and procedures. As a direct-action Paediatrics and the learning from any pertinent clinical presentations have been added as a standard agenda item. Clinical guidelines and National alerts are shared with staff through our governance, clinical and staff meetings and additionally electronically via email, and the Trust would like to reiterate that an audit of effective communication around clinical guidelines and national alerts will be undertaken. We hope that this satisfies the Coroner's concerns in this matter and if there is anything further that the Trust can aid with, please do let us know and we will be happy to address any further issues.

Dear Coroner, RE: Inquest of Riya Hirani 14 September 2023 We write further to the inquest touching upon the death of Riya Hirani, which took place on 14 September 2023. At the conclusion of this inquest, the Coroner issued a Prevention of Future Deaths (PFD) report. The PFD noted that the Coroner had concerns that the junior doctor did not appreciate the severity of Riya’s condition and in essence that incorrect medical treatment was provided. The PFD has been sent to the Trust, as the Coroner believes that the Trust has power to take actions to prevent further deaths. We have provided narrative on the actions already undertaken and future actions as detailed below. Point of care testing Point of care testing is now fully operational within our emergency pathway for measuring and assessing Streptococcus A and respiratory illness in children. New standard operating procedure A new locally devised standard operating procedure (SOP) entitled ‘Paediatric Medical Examination’ is in the development stage and this document details the escalation process for advice and support with clinical concerns both in and out of standard working hours for healthcare professionals when working with deteriorating children both in the emergency pathway and on the Paediatric inpatient wards. As part of this SOP, we are also introducing a SBAR model [which stands for Situation, Background, Assessment, Recommendation], this will help to create an understanding of a shared model around patient handovers and situations requiring escalation or critical

Trust headquarters: Find us online Northwick Park Hospital, Watford Road, HA1 3UJ

+44 (0)20 8864 3232

exchange of information such as sepsis. This SOP also incorporates and supports the principles of Martha’s Law and the ability for families and health professionals to seek second and more senior opinions when remaining concerned after a clinical review. Additionally, the SOP now supports the need for discussion to the next level of seniority and a mandated Face-to-Face clinical review of all children seen within the emergency pathways prior to discharge. The SOP will be due for completion by the end of December 2023. This is currently in draft form and has been shared across speciality, with senior trust clinicians for input and socialisation. We would value input from Riya’s family into the finalised version of the SOP prior to formal ratification and would hope to co-produce the final document with them, but acknowledge this may understandably be difficult for them. Once finalised, the SOP will follow the Trusts governance process for formal ratification and will be shared widely with staff through local departmental, divisional and trust governance meetings. After ratification, the document will be available on the Trust intranet for ease of access and displayed in clinical environments. Our communications department will be approached to share on the trust bulletin and screen savers. As an interim measure pending completion of the SOP all clinicians have been advised through multi professional meetings and via email communication that if a caregiver raises concerns following clinical review the clinician should have a low threshold for seeking senior review. We would be happy to provide the coroner with an update and a copy of the ratified SOP once this has been completed. To provide assurance that this process has been embedded a clinical audit will be undertaken six months after its launch, and at annual intervals thereafter. Nationally approved Paediatric Early Warning System The Trust also confirms that the newly launched Nationally approved Paediatric Early Warning System observation and escalation charts, known as PEWS, will be implemented as per the national requirement. This tool is to support clinicians when assessing children who are acutely unwell or at risk or rapid deterioration and will enable staff to quickly be able to identify deterioration of the child, escalate care, and act on parental concerns. The PEWS charts have been collaboratively developed by clinical teams across England to standardise the approach of tracking the deterioration of children in hospital. Multi-disciplinary working In regard to the care of children with complex medical needs the Paediatric service has a weekly meeting where children with complex medical needs are discussed, and further guidance can be sought from other specialties where needed. The meeting is chaired by

Trust headquarters: Find us online Northwick Park Hospital, Watford Road, HA1 3UJ

+44 (0)20 8864 3232

the Clinical Director of their designated deputy, and attended by the multi-disciplinary team and other clinical specialist disciplines when needed and a plan of care is agreed. The MDT includes a minimum of 6 paediatric consultants, junior doctors and nursing representation. In instances where a patient is acutely unwell and earlier input is required this occurs dynamically, rather than at the weekly meeting. Additionally, the Trust holds a monthly Deteriorating Patients Group. This is chaired by the Trust Medical Director and is an organisational Trust platform to discuss deteriorating patients, where cases are reviewed, and learning is embedded into future practices. This meeting is attended by Director level clinical staff from all clinical specialties and subgroups to ensure collaborative and robust oversight. This meeting is formally minuted, develops actions with named lead professionals and influences Trust policies and procedures. As a direct-action Paediatrics and the learning from any pertinent clinical presentations have been added as a standard agenda item. Clinical guidelines and National alerts are shared with staff through our governance, clinical and staff meetings and additionally electronically via email, and the Trust would like to reiterate that an audit of effective communication around clinical guidelines and national alerts will be undertaken. We hope that this satisfies the Coroner's concerns in this matter and if there is anything further that the Trust can aid with, please do let us know and we will be happy to address any further issues.