Cassian Curry

Coroner's concerns

AI summary

Parents were not informed of a critical consultant plan for a central line review. Concerns also include a lack of consideration for national form suitability and how regional support is accessed for highly vulnerable babies.

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1. Cassian's parents were not told about the Consultant Plan to review, reassess and pull back Cassian's central line. Whilst this was not Cassian's parents’ responsibility, had they known about it they would have acted as a prompt for staff on a busy ward.
2. I heard evidence that the staffing levels on the Jessops Wing are over the national requirements. This therefore led to an assumption that staffing was not an issue or a factor which led to the failure to document Cassian's requirement for review. However, there is a possibility that the number of staff placed an additional burden on the consultant (more junior staff means more questions) and that fewer staff may have offered greater consistency.
3. I heard evidence that the pink sheets have been reviewed and redesigned following Cassian's death and are now more directive. I also heard evidence that these forms are more detailed than the national requirements. Again, there does not seem to have been consideration of whether the national form would actually meet the requirements of this unit and that less information may be preferable in these circumstances.
4. I heard about the Jessops Unit having responsibility, not only for babies already in the unit but also for some of the sickest and most premature babies in the region. I did not hear any evidence of how the Jessops Unit access support from colleagues across the region. I heard evidence of trying to access colleagues to support the Jessops Unit directly and a buddy system but there are other neonatology consultants across the Region who could provide remote assistance potentially if encouraged to think as a system.

Responses

1 respondent

Sheffield Teaching Hospital NHS Foundation Trust NHS / Health Body

17 Jun 2022 PDF

Action Taken

The Trust is working with the South Yorkshire Neonatal Operational Development Network to deliver a network-wide action plan for increased family involvement in neonatal care, and the updated umbilical line insertion checklist now includes a specific entry requirement for informing parents if the catheter is in a suboptimal position. (AI summary)

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Dear Ms Coombes Prevention of Future Deaths Report - Cassian Curry I write to formally respond to your Prevention of Future Deaths (PFD) Report dated 25 April 2022, following the very sad death of Cassian Curry. I am deeply saddened by Cassian's death and sincerely sorry for the distress and pain this has caused his parents. I truly hope that we can learn from Cassian's case and we will take action to ensure as far as is possible that nothing similar happens again. We have reviewed the actions identified in your report and our response is as follows: Utilising the support of parents in the shared care of babies We recognise the key role parents play in the shared care of babies in the neonatal unit. To ensure that there is a consistent approach to this involvement we are working with the South Yorkshire Neonatal Operational Development Network to deliver a network wide action plan for increased family involvement in neonatal care. This approach follows the Family Integrated Care model and philosophy of care within which families are enabled to be primary caregivers to their babies in partnership with clinical teams. This will be phased in during 2022. In addition, the updated umbilical line insertion checklist has been amended and now includes a specific entry requirement for informing parents if the catheter is in a suboptimal position. Has overstaffing been considered as a possible factor in the confusion leading to the failure to handover and document the requirement to review Cassian? We do not believe that the neonatal unit was overstaffed, rather that the contributory factor was the level of experience of the staff on duty. In line with national medical education programmes, junior staff rotate into the neonatal unit on a six-monthly basis. At the beginning of a rotation junior medical staff are PROUD TO MAKE A DIFFERENCE SHE!=FJELD TEACHI G HOSPIT S NHS FOUNOA"TlON Ti'tU :3T 0 0 8 0 8

obviously less experienced and hence require more support and supervision. In order to ensure that there are sufficient experienced staff we have taken a number of actions to mitigate this risk:
• In March 2022, we introduced a second consultant on duty at weekends for 5 hours e ach day to provide additional ward round capacity and a second point of contact for junior staff. This model has been very effective, and a business case is being formulated to enable the recruitment required to make this model permanent and sustainable.
• We are planning to increase the continuity of staffing by: o Increasing the number of Advanced Neonatal Nurse Practitioners (ANNPs). ANNPs are highly experienced nurses who have completed a post-graduate qualification in advanced clinical practice, which means that once fully trained they can effectively take t he place of a junior doctor on the medical rota. The key advantage of increasing the number of ANNPs is that they provide continuity and consistency in terms of staffing, helping to mitigate the risks presented by the rotational nature of junior doctor posts. Our current funded establishment is 4.6 Band 8a ANNPs and 2 Band 7 trainee ANNPs and we presently have 2 ANNPs (8a and 7 grade) and 2 Band 7 trainee ANNPs in post. We are actively recruiting to these vacancies and then plan to increase overall capacity to 10 ANNPs over the next 2-3 years. o Converting some of our present 6 month junior doctor rotational posts to 12-18 month posts at Clinical Fellow level and 2-year International trainee posts. This will provide increased seniority of trainees, better continuity and avoid the changes in capability at the beginning of each 6 monthly rotation. The business case required to enable this change has already been accepted and we aim to recruit to these posts by March 2023 at the latest. Has the thoroughness of the form been considered as a factor leading to the failure to handover and document the requirement to review Cassian? When considering changes to documentation, it is always important to balance a desire for thoroughness, to cover all eventualities, with the practicalities of completion. As reported at the inquest, following Cassian's death, the form has been adapted to provide clarity on target line positions as well as a reminder to involve parents. Whilst these do make the form longer, they were felt by clinicians to be important additions to reduce the risk of reoccurrence of the type of incident which led to Cassian's tragic death. To evaluate the impact of these changes an audit of the new form will be conducted reviewing forms completed during May-July 2022 to assess the current levels of completion and identify whether there is further scope for improvement or indeed simplification. As part of this process, we will review the documentation used in other neonatal units in order to benchmark practice. Additional and different staffing models have been considered, but how are the rest of the system being brought together to support at times of particular pressure? The neonatal unit in the Jessop Wing is part of a network, however as the tertiary centre, the department needs to be central to discussions and decisions regarding very poorly babies who may need to be transferred to the unit. The consultant body believe that the altered staffing models described above will provide appropriate cover, including seniority and experience, to allow the unit to meet demands. An escalation guideline has been produced which includes involving additional consultants at times of particular pressure or surge in activity. The unit continues to monitor activity and acuity and options to increase staffing, for example having an additional junior doctor at night, will be explored if baseline activity levels are shown to be increasing over the coming years. PROUD TO MAKE ADIFFERENCE 0 0

In addition, the department is looking at other initiatives to reduce the pressure on staff. These include the introduction of an Electronic Patient Record (EPR), which will be implemented in July 2022. This will reduce the administrative workload for junior doctors and provide increased clarity of documentation allowing consultants to have a better overview of patient care. In addition, the EPR will allow automated fluid infusions and observations to be recorded, releasing time for nurses to provide more cli n ical care for babies. Having outlined the actions we are taking in response to your report, I hope that I have been able to convey how seriously we have viewed this matter. We are absolutely committed to learning from Cassian's death and implementing these actions. Finally, I hope that my response has addressed the concerns and actions you identified in your Report. Please contact me if you have any queries or points of clarification.

Report sections

Investigation and inquest

On 7 July 2021 I commenced an investigation into the death of Cassian Curry born on 3 April 2021. The investigation concluded at the end of the inquest on 22 April 2022. The conclusion of the inquest was:- Cassian Curry was born at the Jessops Wing, Sheffield on 3 April 2021. He was 28 weeks and very small even for his age. On 3 April 2021 an umbilical venous catheter was positioned in a sub optimal position and therefore required review within 24 hours. The review was not documented in Cassian's records or referred to in handover or ward rounds and as a result, not done. This resulted in Cassian's death on 5 April 2021. Cassian's death was contributed to by neglect. The medical cause of death was: 1a: Total parental nutrition-related cardiac tamponade 1b: Complications arising from central umbilical venous catheter insertion 1c: Prematurity 2: Maternal Arterial Malperfusion

Circumstances of the death

Cassian was born at the Jessops Unit, Sheffield on 3 April 2021. He was born at 28 weeks gestation weighing 750g. Despite that he was strong and appeared to be doing well. On 3 April 2021 an umbilical venous catheter was provided to Cassian. Unfortunately, the placement of this line took longer than they would have hoped and as a result Cassian's temperature decreased and the procedure had to be stopped. The line was left in a sub optimal position however it was acceptable to commence parental nutrition through it. The Consultant formed a plan to review, reassess and pull back the line within 24 hours. She did not document this or hand it over and the result was that Cassian's line was not pulled back. Unfortunately, this resulted in total parental nutrition-related cardiac tamponade and Cassian's death on 5 April 2022. I made the following findings in the inquest:-
1. There were no systemic failures in the form of staffing issues which caused or contributed to Cassian's death. I say this on the basis of the evidence that I have heard that staffing at the Jessops Unit over the weekend of Cassian's birth and death were above the national requirements. Although there were a number of junior staff, they were appropriately qualified and able to support the Unit adequately.
2. Cassian was in a dependent position and that a duty of cared was owed to him.
3. The placement of the Umbilical Venous Catheter was a complex procedure. The evidence which I have heard is that this was a routine procedure, and it was safe for this to be performed by Junior Doctors. That said the clear evidence of Dr is that the placement of such a catheter is 'one of the most complex procedures in the neonatal unit'
4. The decision to pause the procedure to place the umbilical venous catheter on 3 April 2021 was reasonable and appropriate on the basis of the clinical picture of Cassian at the time. This includes the decision to leave the line in situ at that time and commence parental nutrition.
5. The Consultant Plan to review, reassess and pull back the line within 24 hours was equally reasonable and appropriate on the basis of the clinical picture.
6. The Consultant plan to review, reassess and pull back the umbilical venous catheter was not adequately recorded or communicated. The plan should have been reflected on the pink sheet. Dr placed the pink sheet in front of Dr who signed it but did not record any plan on that sheet. The need for the venous catheter to be pulled back was not communicated with Cassian's family. Dr sought clarity about the position of the line from Dr who confirmed she was aware, but this was still not sufficient for the plan to pull the line back to find its way into either Cassian's notes or the ward round. Dr had a verbal handover from Dr on 4 April 2021 and again, although Dr handed over specific elements of Cassian's clinical picture, on the basis of her own evidence she 'forgot' to hand over the need to reassess the line.
7. The Consultant Plan should have been recorded in Cassian's notes
8. The Consultant Plan should have been communicated with Cassian's parents
9. The Consultant should have recognised that following Dr query her plan may not have been sufficiently clear and the notes ought to have been reviewed and this plan prioritised during the ward round
10. The Consultant should have handed over the plan to the next Consultant on duty as part of the handover
11. The complexity of the initial placement of the umbilical venous catheter or indeed the procedure to pull this back is a red herring. The failing here is one of recording and communication.
12. There was a failure to record the Consultant Plan appropriately on Cassian's pink central line sheet. There were then subsequent failures to hand over the Consultant Plan to other members of the team and Cassian's parents.
13. The failure to adequately record and communicate the Consultant Plan was a gross failure of Cassian's care. To be satisfied that there was a gross failure of care for Cassian I do not need to be satisfied that there was one specific event which would amount to a gross failure. I am entitled to consider a number of failures which, when viewed collectively, amount to a gross failure. It could be said that the failures in this case were a number of individual failings, or one perpetuated failure started with the failure to record the Consultant Plan on the pink central line sheet and the continuing in failing to handover these matters to members of Cassian's care team in spite of a reminder from Dr .
14. The failure to record and communicate the Consultant Plan to review, reassess and pull back Cassian's central line contributed to his death and contributed in a way which was more than minimal, negligible or trivial. I have reached this finding on the basis of the evidence from Dr that but for this incident Cassian would not have died of what he died of when he died.

Action should be taken

I would ask that your responses specifically consider the following:-

1. Utilising the support of parents in the shared care of babies
2. Has overstaffing been considered as a possible factor in the confusion leading to the failure to handover and document the requirement to review Cassian?
3. Has the thoroughness of the form been considered as a factor leading to the failure to handover and document the requirement to review Cassian?
4. Additional and different staffing models have been considered but how are the rest of the system being brought together to support at times of particular pressure?

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