Nasar Ahmed

British Society for Allergy and Clinical Immunology Studio 16, Cloisters House, 8 Battersea Park Road, London SWB 4BG Tel: +44 (0) 207 501 3910 bsaci Fax: +44 (0) 207 627 2599 improving allergy care Email: info@bsaci.org through education, training and research Website: www.bsaci.org To: Coroner M E Hassell Senior Coroner Inner North London St Pancras Coroner's Court Carnley Street London IC 4PP 13 JUL 2017 I Tuesday July 11th. 2017 Rcgulntion 28: Prevention of Future Deaths Report: Re: lnqucstintothedcath ofNasarAHMED (dicd 14.11.16) Thank you for forwarding a cop} of the investigation into the death of asar Ahmed. You have asked me. as President of BSACI. to respond to your report and to set out details ofaction taken or proposed to be taken in response to your report. The British Societ) for Allergy and Clinical Immunology (BSACI) is the society that represents professionals who work within the field of Allergy in the UK. BSACI has a long track record of providing resources 10 both our members and to the wider professional community to support practice in dealing with allergic conditions. The circumstances around Nasar's death are 1101 novel to this Society and, therefore, for many years we have provided guidance in order 10 reduce the risk ofsimilar cases in the furure. We have produced a number of national guidelines using a process accredited by N JCE (National Institute of Care Excellence) and these include the following: I. BSACI Guidelines for the Management or Egg Allergy (20 I 0)
2. BSACI Guidelines for Diagnosis and Management ofCows Milk Allergy (2014)
3. BSACI Guidelines on Adrenaline Auto-injectors (2016)
4. BSACI Guidelines on the Diagnosis and Management of ul Allergy (2017) In addition. we have promoted 1he use of wriucn personalised emergency 111anagcmcn1 plans for anaphyl~ctic reactions. We have developed templates which can be used by all hcallhcare professionals available on the BSACI wcbstte and these can be tailored to each individual 's personal circumstances and allergies. BSACI have also been pa11 of a campaign 10 ensure that schools cnn hol? _spare adreln~linc aAuto~Onjl~cto~;\~:~:1~1~/~~:~:!'i:~: · · · d d 1 10 the Human Medicines Re0 u at1ons Ct -
-· for use in emergencies. This require an amen men . . k/:d/ ko '/2017/7 15) The revised regulations will week that the amendment has been accepted (hnp://www.leg1slat10n.~ov.u I"• u
-injectors .without prescri1ltion for use in ·11 II hools to buy a rcna me au -
• . d come into elTect on I October ~0 17 an _w1. a. ow sc .. , . . vidcd it is done on an occasional basis and not for pro ht. emergencies from a pharmaceutical supplier Ill small qua~111tu.:: J)IO I. I will provide online resources to suppon school staff Furthermore a working group has been set up 10 develop ,1 we s11e " 11c l with this. Ir you would like to discuss the contents of my . . . th sc BSACI initiatives is available on www.bsaci.org. Further mforrnat1on on e letter I would be pleased to speak to you. With kind regards

Dear Madam Coroner, Inquest into the death of Nasar Ahmed - Response to Regulation 28 Prevention of Future Deaths Report This is a response on behalf of Compass Wellbeing ('CWB') to your Regulation 28 Prevention of Future Deaths Report issued following the inquest into the tragic death of Nasar Ahmed. CWB have carefully considered each of the matters of concern raised by you and this response addresses each concern in turn setting out the action taken or proposed to be taken, along with a t imetable for the actions. The purpose of this reply is to set out and demonstrate the actions taken by CWB to ensure that similar deaths do not occur in the future. Following the death of Nasar Ahmed and prior to the inquest commencing in May 2017, CWB undertook an internal investigation into the actions of the staff member directly involved, established core facts and sought to learn lessons from our failures and those of the School Health Service to ensure as best we can that those are not repeated. You may recall that one of our senior members of staff gave evidence to you and the family in May about the steps that were being taken and we take this opportunity to answer your 4 questions and also update vou on the further action the organisation has taken. Steels Lane Health Centre, 384-398 Commercial Road, El OLR Registered in England: 08451249

l' compass wellbeing
1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar's medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist It is established practice that at each child's review meeting, all of the child's medication must be physically present and visually checked by the school nurse. The review must then be recorded in the Child's Health Record and any action points followed up accordingly. It is evident from an investigation carried out by CWB and the evidence given at the inquest into the death of Nasar Ahmed that, on this occasion, our (Nurse) staff member did not carry out a visual inspection of the medication at Nasar's review meeting in May 2016. That is a matter of very deep regret. All of CWB's school nurses receive 'Health Care Plan' t raining as provided by CWB which specifically covers the requirements for reviewing medication and how and when this must be undertaken. The Nurse in this case attended that training in June 2015 and we have attempted to understand whether the failure was an individual one or is wider. We have established that the Nurse had previously undertaken two periods of study successfully completing a practice portfolio demonstrating a knowledge and understanding of reviewing medication during a Health Care Plan meeting. We therefore believe that the Nurse was fully aware of the requirement for medication to be physically present and visually inspected at a review meeting and he should have done so in May 2016 when Nasar Ahmed's medication was reviewed. StepsTaken We have reminded all of our staff that there are no circumstances when a school nurse would not be expected to have the medication in front of them when conducting a review. Our staff have been reminded that we would consider a similar breach to be an act of gross misconduct and would also result in a professional conduct referral. To assist with ensuring that medication is visually inspected by school nurses across the service at review meetings, a checklist has also been introduced for use during Individual Health Care Plan ("IHCP") review meetings. This new measure is designed to ensure that all areas of the review process have been covered during the meeting. This new checklist will act as guidance and prompt to all school nurses and, once completed, will be scanned onto the Child's Health Record. A copy of the 'School annual review asthma/wheeze checklist' is enclosed. The completion of this checklist will form part of the bi-annual IHCP audit, further details of which are provided later in this response. Steels Lane Health Centre, 384-398 Commercial Road, El DLR Registered in England: 08451249

l' compass wellbeing As part of their investigations, CWB have undertaken a wider review of the School Health Service, records kept and IHCPs, all of which are key areas in working to ensure that IHCP and medication reviews are conducted correctly and in a t imely manner. In December 2016, CWB carried out a sample audit of IHCPs to review a cross-section of IHCPs and identify any areas that required improvement across the service. The findings showed that the IHCPs were of a good standard overall. During this review, there were examples of high standards of documented care however, it was noted that there was a lack of consistency across practitioners in terms of recording and articulating details of care plan meetings. As a result of this sample audit, it was identified that there was a need for a more robust approach ensuring that all children requiring an IHCP have one that is in date and fully and consistently detailing the support required; including a particular focus on identifying what action is to be taken in the event of an emergency. An IHCP improvement plan was subsequently implemented to identify, review and monitor all IHCPs across the service using a centralised database. This will support the identification of IHCPs requiring review which will be automatically flagged to the senior management team by an identified data manager. The database has been designed with a flagging system in it. The system counts down in days when an IHCP is due to be renewed and turns the date yellow 60 days prior to the expiry date and red once the date has arrived. The database will be managed by a data team on a daily basis and details of IHCP due (within 60 days) sent via email to the individual nurse responsible for the school and their line manager. This will be overseen by the clinical lead for the service and monitored as part of the performance data for the service. A full Quality Standards Audit was commenced in June 2017 for IHCPs and is due to be completed in August 2017. This audit will review all IHCPs across the whole service. Once this audit has been completed, the annual audit schedule will be extended to include IHCP audits on a bi-annual basis. We will put in place a robust action plan to deal with any deficiencies identified. CWB has also fully reviewed and identified the training received by school nurses and what they are required to receive in order to complete IHCPs in line with CWB's Competency Framework. The Competency Framework is a learning and development resource for nurses and this is completed upon their induction to the service. Re-training has been delivered in line with this Competency Framework. IHCP training has also been undertaken by all staff on 22 June 2017 in order to re-emphasise the role of a qualified nurse with reference to the guidance and the support of administering medication by non- Steels Lane Health Centre, 384-398 Commercial Road, El OLR Registered in England: 08451249

l' compass wellbeing registered (NMC) individuals. As part of the re-training exercise staff were told of the tragic events of this case. In addition to the above training, the bi-annual training received by the school nursing service was delivered in June 2017. During bi-annual training, the service is suspended and training takes place across all staff groups. The training has been tailored to support the key learning points from the tragic death of Nasar Ahmed and the requirements and expectations of a school nurse. It covered a range of key areas including how to improve record keeping and the importance of this, the increased function of school nurse administrators in communication and following up actions with key staff in school and the parents, the use of electronic diary systems and diary management. A copy of the training schedule undertaken in June 2017 is attached. Specific IHCP training will continue to take place on a bi-annual basis. The next scheduled training is for September 2017. We believe that there is now in place a rigorous and proactive approach to auditing, reviewing and monitoring of IHCPs and we are determined to re-enforce the correct medication review process is followed by all of our staff.
2. Although Nasar's mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting CWB recognises and understands the importance of the collaborative working arrangements involved in preparing IHCPs and the ongoing support, communication and processes for children in schools with medical conditions. The Supporting Medical Needs Policy clearly sets out that a number of organisations have roles and responsibilities and that school staff, school nurses and parents must work in partnership to ensure that the needs of pupils with medical conditions are met effectively. Steps Taken Following Nasar's sad death CWB have prepared a Partnership Agreement between CWB and schools across the Borough of Tower Hamlets. This agreement sets out arrangements for support and training for education staff, as well as detailing the expectations across the organisational boundaries. Page 7 of the Agreement (copy enclosed) outlines the roles and responsibilities of the School Health Service and the school. It specifically requires that a member of staff will be identified who will liaise with the School Health Service. The identified school staff member is the person responsible for that child and who has Steels Lane Health Centre, 384-398 Commercial Road, El DLR Registered in England: 08451249

compass wellbeing the appropriate levels of authority to agree possible actions generated from an IHCP and who is able to disseminate information regarding the child's care across the school, including what to do in an emergency. The staff member will work to ensure support and consistency is provided by the school and School Health Service, particularly in relation to the creation of IHCPs and attendance at review meetings. CWB is currently working with the London Borough of Tower Hamlets Public Health and Education departments, as well as Tower Hamlets head teachers representatives, to finalise and roll out the agreements across all schools. Alongside this, joint letters have been sent to all school head teachers within the Borough of Tower Hamlets detailing how schools can become "asthma friendly". This also out lines the expectations and requirements of the school and the School Health Service. This has been prepared and sent in partnership with the specialist teams led by (from whom you heard evidence at the inquest). Furthermore, as part of this partnership, CWB with the assistance of the respiratory clinical nurse specialist, has revised an asthma plan template for children and a process for sharing individual asthma plans with the school nursing service and schools has been commenced. A child's individual asthma plan created by the GP/practice nurse or the specialist team will now be sent directly through to the School Health Service via secure generic email accounts. These email accounts are monitored on a daily basis. The plan will be attached to the child's health record and an email alert sent to the relevant school nurse. Training has been given to our staff team. In addition, school nurses are being supported to actively encourage appropriate members of education staff in the schools to be present during IHCP meetings. All school nurses are aware of the draft Partnership Agreement (see above) which states that there is a requirement for a school staff member to be present at these meetings. With the support of senior managers, school nurses will work to encourage the presence of school staff in IHCP meetings. CWB has also initiated a Project Plan for an incident reporting system called the 'Radar Incident Reporting System'. This system is used to record incidents and risks within the organisation and also highlights where communication difficulties occur, including where IHCP meetings need to be postponed due to non-attendance of education staff. The Radar Healthcare risk register will enable CWB to fully record and manage the major risks to the organisation and t he objectives that they compromise. Risks are prioritised and can be linked to existing incidents and complaints that have been recorded. The system allows regional and corporate risk registers to be managed, with actions, alerts and reviews being tracked to ensure effective risk management. Steels Lane Health Centre, 384-398 Commercial Road, El OLR Registered in England: 08451249

l' compass wellbeing The automated workflow and alert system for each event type ensures that there is a consistent approach to reporting, recording and managing events through the use of electronic event recording forms. Once completed, the event forms generate workflows including identifying reporting lines and governance arrangements and incorporating configured templates to help in performing effective investigations, root cause analysis and trend reporting. The project is being implemented in a number of phases which are set out at page 3 of the attached document. Phase 2 and the training on the use of the Radar system is to be undertaken in August 2017 and it is expected that once Phases 3 and 4 are completed in early September 2017, the system will be fully rolled out to all staff for use. These steps have been taken to ensure that all those involved in the effective care and support of children in schools with medical conditions work effectively and collaboratively and that there is an identified member of staff within each school to play a pro-active part in the preparation and updating of IHCPs and to attend review meetings.
3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar's medication box contained an EpiPen without any description of when or how to use it In evidence to you the Nurse accepted that he used the incorrect care plan. CWB's investigation has concluded that the Nurse had not reviewed the previous IHCP from October 2014 marked "Allergy Action Plan (Severe with Asthma)" or the updated April 2015 IHCP, again marked "Allergy Action Plan (Severe with Asthma)". Both of these previous plans were readily available to the Nurse as they had been uploaded to the EMIS (the electronic health record system} to which he had access. Paper records were also made available to him. When a school nurse is preparing to review an IHCP, it is established practice that they should go onto the EMIS and review the previous IHCP. This did not happen on this occasion. It has further been accepted by the Nurse that even if he did not have access to or see the previous plans, he should have completed the "Allergy Action Plan {Severe with Asthma)" for Nasar Ahmed based on the information he had available to him at the time. As part of CWB's investigation, each of the IHCPs prepared by this Nurse at Bow School were reviewed. CWB's investigation found that other IHCPs prepared by the Nurse had errors in them and were required to be re-written. That process has now been completed. Steels Lane Health Centre, 384-398 Commercial Road, El OLR Registered in England: 08451249

l' compass wellbeing Steps Taken The Coroner is referred to the steps set out in response to the first concern raised and the processes that have been implemented across the service to provide assurances in relation to the auditing, quality and consistency of IHCPs prepared and completed by school nurses.
4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan wit h the dose of the relevant medication The Supporting Medical Needs Policy indicates that the responsibility of checking that in-date medication is provided is a shared one between the school itself and the school nurse. It is fully expected that the school nurse and the school would have a conversation to discuss follow-up actions arising from a meeting and appropriately diarise to check that the correct medication has been received and, if not received, to chase this up in a timely manner. As a qualified health professional, the school nurse is able and expected to understand whether a prescription is appropriate and whether the correct medication has been received. Any outstanding actions must be followed up and completed as a matter of course and in accordance with their professional duties. As referred to above, CWB has carried out an investigation into the actions of the Nurse, including his failure to diarise to ensure that the current medication was provided and in the box. As was evident from the Inquest, the investigation findings are that the Nurses' diary made no mention or record of any follow- up action relating to checking the medication. There is no evidence to show that he checked the medication had been received and was in Nasar Ahmed's box and that is a matter of very deep regret. Steps Taken CWB have implemented additional measures to ensure that the checking and updating of actions from IHCP meetings are routinely followed up by all school nurses and to prevent this event from happening again. All clinical staff have received guidance on how to manage an electronic diary in order to assist staff in diarising appointment, reminders and sharing calendar appointments. All clinical staff have access to mobile working devices, tor example laptops, and the service is moving to a fully electronic diarising system in order to support sharing of appointment calendars and the effective use of an electronic diary and reminder system. Specific training on electronic diarising and the use of this took place on 21 June Steels Lane Health Cent re, 384-398 Commercial Road, El OLR Registered in England: 08451249

ii compass wellbeing 2017 and we believe that the system is fully understood by our staff team. The system will be fully rolled out in the new academic year (September 2017). Furthermore, the bi-annual training referred to earlier above will also cover the use of electronic diary systems and diary management and act as a reminder of our expectations. Having an electronic diary system in place operated by trained staff will enable appointments to be clearly made and set out within the calendar and reminders and electronic prompts to be set. This will assist in ensuring that actions are followed up on a prompt and routine basis. We have told our staff that they should not be afraid of letting us know if they are struggling to 'get to grips' with the electronic system of working. CWB have re-enforced to all staff the requirement and expectation across the service to ensure that accurate and contemporaneous records are kept, including recording and documenting action points and dates for follow up, as well as documenting who is responsible for each action point. This has been re- enforced through medico-legal training which was arranged for all staff in order to address the implications of poor documentation keeping and the effect this has on the delivery of healthcare. This training took place on 19 June 2017. The requirement and importance of record keeping is also set out within CWB's Competency Framework which states that there is a need to "ensure all records are written contemporaneously and in accordance with the NMC record keeping standard and local record keeping and documentation standards and guidelines including local electronic documentation, storage and deletion policies". As referred to previously within this response, this is a framework reviewed and completed by school nurses upon their induction to CWB. Whilst we wish to avoid repetition we confirm that training in relation to this framework and the relevant competencies has been re-run. We hope that this response provides clear and substantive evidence of the actions taken by CWB to prevent future deaths. However, should you require any further information or clarification, please do not hesitate to contact us.

St Andrews Health Centre 2 Hannaford Walk London, E3 3FF Tel: 020 8980 1888 Fax: 020 8980 2753

Partnership

The Bromley by Bow Health Partnership Creating Healthy Communities

02-Jul-2017 Coroner ME Hassell Senior Coroner Inner north London St Pancras Coroners court Camley Street London NC1 4PP

Response to the Prevention of future deaths report following the death of Nasar Ahmed

I am writing to you on behalf of Bromley by Bow health partnership in response to the matters of concerns raised by the coroner’s inquest in the 'prevention of future deaths report' following the death of Nasar Ahmed.

We have been deeply saddened by the events and death of this child and the impact it will have had on the family- our thoughts are with them.

Following the events that have occurred, these are just some of the steps we have taken:
- We have discussed the case multiple times as a team and taken steps as a team to identify areas of good practice and areas for learning.
- We have discussed the case individually with all those involved in Nasar's care (nurses, GPs, clinical pharmacist) and each consultation has been thoroughly reviewed.
- We have contacted the pharmacy he collected medication from to discuss the matter and improve our understanding.
- We have been in contact with the borough safeguarding team to provide information in order to support discussion at the serious case review panel for further learning.
- We have also been in contact with the hospital paediatric respiratory team to arrange a meeting for further learning.

I will now specifically respond to the 4 main points raised in turn.

St Andrews Health Centre

2 Hannaford Walk London, E3 3FF Tel: 020 8980 1888 Fax: 020 8980 2753

Partnership

The Bromley by Bow Health Partnership Creating Healthy Communities

Point 1 states that Nasar's report of symptoms to his consultant didn't correlate with the GPs findings, that his lung function tests were good, that GP prescribed 30 inhalers which is a recognised risk factor for death and that he should have been seen by the consultant again. The point queries whether an automatic flag could be raised if excess medication is prescribed.

There is already a mechanism in place via our Emis patient records system which flags a pop up alert anytime excess short acting beta agonist inhaler prescriptions are given- this is if more than 12 are issued in the last 12 months. The patient is flagged as high risk and if we haven't already, we would contact the patient/parent to book in for an asthma review.

These patients also get flagged up on our recall list for ‘enhanced asthma review’. We currently run searches for those deemed as high risk patients (i.e. those that have a high use of SABA inhalers more than 6 per year, more than 2 asthma exacerbations per year, recent hospital or A&E attendance or high dose inhaled steroid therapy) and proactively invite these patients for review as a priority for enhanced asthma reviews.

Nasar was proactively invited for an enhanced review as he was flagged up in such a way demonstrating that the flag does pick up such patients. This review took place on 15th Feb 2016 and this is where he was discovered to have poor inhaler technique. Time was spent teaching him the correct technique for his preventer and reliever medication. The report suggests he should have been seen by the consultant again. He did indeed get seen 5 days after this consultation in a consultant clinic. On 19th Feb he was seen by a specialist registrar. We believe that the registrar did not flag him up as a high risk patient because following the correction of his inhaler technique by our team, his symptoms and lung function tests were much better. He had further follow up appointments organised by us after this in March and it did in fact show that his asthma control score had improved to 24/25. Nasar was invited again in August 2016 proactively for another enhanced asthma review. Our notes indicate that our recall team called the family and reminded Dad the day before that Nasar had an appointment for the on 31st august. The clinician conducting the consultation also called prior to the appointment to remind family to bring in inhalers so that inhaler technique could be checked again, unfortunately, these were forgotten by the family and so a note was made by the clinician that the inhaler technique needs to be checked again at next follow up. At this point, the Asthma test score was again 14/25. There was no specified time period for follow up or review. However, there was a further entry on 14th

St Andrews Health Centre

2 Hannaford Walk London, E3 3FF Tel: 020 8980 1888 Fax: 020 8980 2753

Partnership

The Bromley by Bow Health Partnership Creating Healthy Communities

October 2016 in the notes where we contacted the parents to come in for a medication review with a GP.

On review of the literature, there is no specified guidance about what actions should be taken with different levels of asthma test scores- just that a score less than 20 may indicate poorly controlled asthma. Further national level guidance on this may be useful to avoid variations in action. At a clinical team meeting on 27th June 2017, we reflected on the point that at Nasar’s August 2016 asthma review, there was no follow up specified for the patient on finding that his asthma test score was 14/25. It was agreed that all clinicians must document specified follow up if the asthma test score is found to be suboptimal (i.e. <20/25). Who this review should be with and how soon it should take place would be agreed with the patient/parent on a case-by-case basis. This will be implemented immediately i.e. from June/July 2017. We hope this addresses all the queries raised in point 1. Whilst we believe our processes work well, following the event we have taken steps to tighten these even further.

Point 2 states that the asthma pump in Nasar's medication box was an accuhaler which is inappropriate for an emergency situation and that the appropriate inhaler should have been prescribed with a spacer. You wonder whether there is a wide spread lack of understanding about this.

As a team, we have reviewed national and local guidance around appropriate prescriptions of inhaler devices. We have discussed this with nurses, specialist pharmacists and the rest of our clinical team. The guidance suggests, and widespread practice is, to prescribe the inhaler type that best suits the child. In Nasar's case this was an accuhaler. We could not find any guidance that those prescribed an accuhaler for preventer use should also be prescribed a metered dose inhaler with an aerochamber to be kept at home/school for emergencies. Furthermore, throughout all his specialist hospital reviews, this was not a suggestion made by our paediatric respiratory specialists.

We reviewed BTS/Sign guidelines 2016 and the national review of asthma deaths audit
2014. BTS/SIGN (2016) stated:

Specific evidence about the pharmacological management of adolescents with asthma is limited and is usually extrapolated from paediatric and adult studies. Specific evidence about inhaler device use and choice in adolescents is also limited.

St Andrews Health Centre

2 Hannaford Walk London, E3 3FF Tel: 020 8980 1888 Fax: 020 8980 2753

Partnership

The Bromley by Bow Health Partnership Creating Healthy Communities

INHALER DEVICES- Adolescent preference for inhaler device should be taken into consideration as a factor in improving adherence to treatment. As well as checking inhaler technique it is important to enquire about factors that may affect inhaler device use in real life settings, such as school. Consider prescribing a more portable device (as an alternative to a pMDI with spacer) for delivering bronchodilators when away from home.

On discussion we felt that it may be an expert opinion to additionally prescribe another inhaler with an aerochamber for emergency situations such as this but there isn't any broader local or national guidance that recommends this and if this is the most appropriate action, this needs to be highlighted at national level to feature in guidance so that systemic change can take place both within general practice but also at hospital level. We agree that an accuhaler is not suitable for an emergency situation where a patient may not have enough respiratory effort to take in the medication appropriately so as a practice we agreed that for patients using accuhalers, we would issue an MDI with spacer for use in emergencies and make it clear what this is for in the asthma review. This will be implemented from July 2017.

Point 3 suggests that there must be a way of ensuring that a school care plan is accurate, up to date and that there are identical copies stored at home, school, GP surgery and within hospital records.

We are currently in contact with our borough children’s safeguarding team to determine whether School nurses have access to the community version of our patient record system so that information about care plans can be input into this and this can be shared between us and the school nurses. Some hospital departments also have limited access to our patient record system- this may be a good way to share information. There needs to be borough wide (and national consideration around this). From a practice level, our clinical teams are checking for up to date and accurate care plans during asthma reviews- however, this case has further highlighted the importance of this.

As a practice, we have agreed that our nursing team (who conduct the majority of our asthma reviews) will post/email a copy of the asthma action plan to the child’s school health team and/or a copy will be given to parents to hand into the school. This change will be implemented from July 2017.

Point 4 asks if there is a way of disseminating info more widely around the appropriate indications and use of IM adrenaline.

St Andrews Health Centre

2 Hannaford Walk London, E3 3FF Tel: 020 8980 1888 Fax: 020 8980 2753

Partnership

The Bromley by Bow Health Partnership Creating Healthy Communities

All our staff receives yearly BLS training and training around anaphylaxis. During this training the points above may or may not be emphasised by the trainer. We would share our learning around this at borough wide level with the safeguarding children team and discuss whether change can be implemented such that trainers organised to deliver this training emphasise the points highlighted if they also agree with these. By the end of September 2017, our nursing team will investigate whether there are anaphylaxis care plans that are already in place and being used by secondary care. We will then be incorporating these into care plans when seeing patients with asthma and allergies who have adrenaline prescriptions.

I hope all your points have been addressed. We are keen to work with all willing partners to improve the care of patients with asthma and will be happy to provide any further information as required.

Regards

GP Partner – Bromley by Bow health partnership