Sydney Neil

Dear Mrs Hunt; Re: Regulation 28 Sydney Mya Neil Thank you for sharing a copy of your Regulation 28 report regarding the sad death of Sydney Mya Neil: This was a tragic case of a young girl, suffering from severe brittle asthma, who suffered severe exacerbation f her asthma at school. At the inquest, you determined that there was ineffective ventilation due to the lack of available oxygen and obstruction of her airways by vomit: You have raised the following concern:- The absence of either suction equipment or oxygen at Wychall Lane Surgery which led to inadequate ventilator support being given for minutes pending arrival of the ambulance service and the level of expertise in GP practices when resuscitation is required and whether GP surgeries are adequately equipped to deal with emergency situations_ Background Asthma UK and other sources, suggest that up to 5.4 million people in the UK are currently receiving treatment for asthma and it accounts for high numbers of consultations in primary care out-of-hours services and hospital emergency departments_ During 2011-2, there were over 000 hospital admissions for asthma in the UK and whilst the number of deaths from asthma is falling, the number of reported asthma deaths in the UK remains amongst the highest in Europe National Review of Asthma Deaths (NRAD) was commissioned by the Healthcare Quality Improvement Partnership (HQIP) on behalf of NHS England, NHS Wales, the Health and Social Care division of the Scottish government; the Department of Health, and the Northern Ireland Department of Health , Social High quality care for all, now and for future generations 65,C

Services and Public Safety (DHSSPS): Its report 'Why asthma still kills' was published in May 2014. recommendations included the following_ Better education is needed so that doctors, nurses and other healthcare professionals are aware of factors that increase the risk of asthma attack and death. Every NHS hospital and general practice should designated, named clinical lead for asthma services, responsible for formal training in the management of acute asthma_ Asthma patients prescribed more than 12 reliever inhalers in a year should have an urgent review of their asthma control. Follow-up arrangements should be made after every attendance at an emergency department for an asthma attack. After discharge from hospital for asthma, patients should be followed up in hospital outpatients. People with asthma should have a structured review by a doctor or an asthma nurse with specialist training at least once a year. People with asthma should be provided with personal asthma action plan (PAAP): This is a written record of the discussion that a patient has with their GP or asthma nurse about their asthma care to help them manage the condition. Guidance In England, a structured approach to the management of asthma is supported by the Quality Outcome Framework, which incentivises practices to offer all patients diagnosed with asthma an annual review_ The current guidelines for optimising asthma management are the 2014 quidelines_published by the British Thoracic Society (BTS) and Scottish Intercollegiate Guidelines Network (SIGN) The 'British guidelines on the management of asthma'/ highlights the challenges of managing 'brittle' or 'difficult' asthma similar to Sydney's condition. The guidance recommends that patients with difficult asthma should be jointly managed with shared care arrangements between primary and secondary care. Patients should be managed by 'personal asthma action plan' and as highlighted in the NRAD report; in the case of such brittle disease this should advise a patient in the event of an emergency situation to access secondary care services directly: The BTSISIGN guidelines concur with your findings that supplementary oxygen should be available in all health care settings including GP surgeries and states that in addition , nebulisers for giving nebulised B2 agonists bronchodilators should preferably be driven by oxygen: SIGN 141 British Guideline on the_management of Asthma October 2014 High quality care for all, now and for future generations Key have

The Care Quality Commission (CQC) as the regulator of general practice needs to be assured that practices are able to immediately respond to the needs of person who becomes seriously ill. The CQC does not have explicit guidance around emergency equipment; however does state that if the practice does not have oxygen they are unlikely to be able to demonstrate are equipped for dealing with emergencies_ In determining what equipment and training general practice should have; the CQC will consider the individual circumstances of the practice such as the practice's ability to access emergency services in a timely manner: On this basis _ unless practice is based in particularly remote or inaccessible location practices should be able to rely on rapid access to emergency services when planning what equipment and' training is appropriate to meet the needs of patients in primary care In relation to the requirement for suction facilities to facilitate ventilator support; have sought the views of NHS England's National Clinical Directors Whilst number of practices will have some access to suction facilities it was not felt that this should become national requirement of primary care_ BTS guidance highlights the risks associated with ventilatory support and non-invasive ventilation, (NIV) in severe asthma_ It is the view of my Clinical Directors therefore better to target training in primary care on recognising an emerging emergency situation rather than to attempt to train and maintain skills in using suction equipment in challenging emergency situations. As result; do not feel it appropriate to mandate all general practices to purchase and maintain suction facilities which would necessarily include ensuring all relevant staff are appropriately trained. Action agree that the action that must arise from this tragic case is the need to ensure that the health service doesn't become complacent in its management of asthma The NRAD published in 2014 has highlighted 6 key recommendations which would make a difference to the numbers of people who die each year because of their asthma These recommendations have informed the General practice Quality Outcome Framework, supporting individualised personal asthma plans for asthmatic patients. It is recognised however that we need to go further to embed these improvements into routine clinical practice. The 2016 update to the BTSISIGN asthma guidelines is due to be published in the Autumn and will use this as an opportunity to raise awareness of asthma management in primary care. will do this by communicating to all GP practices through our GP Bulletin_ also intend to share this with the CCGs who commission secondary care and emergency services. have asked Head of Primary Care Commissioning, NHS CQC has published agreed nciples for defibrillators oxygen and oximeters and Cardiopulmonary Resuscitation in general practice High quality care for all, now and for future generations they key May pri

England to write to Steve Field, CQC Chief Inspector for primary care, to ensure the CQC through its inspection regime, ensures that primary care services carry the necessary equipment and skills to address respiratory emergencies: the above has provided some reassurances that NHS England has taken your concern on board,

Dear Mrs Hunt Sydney Mya Neil (deceasedl Following receipt of your previous correspondence in respect of this unfortunate incident; the CCG has reviewed the current GP contract, the national guidance and best practice available from the Care Quality Commission (CQC) , the General Practitioner's Committee (GPC), the Local Medical Committee and the Resuscitation Council (UK): The CCG view would be that the following would be the basic equipment requirement for General Practice in relation to the management of cardiorespiratory arrest: #List taken from the Resuscitation Council (UK) Equipment and drug lists Primary Care Minimum suggested equipment: Protective equipment gloves, aprons, eye protection. Pocket mask (adult) with oxygen port (may be used inverted in infants). Oxygen cylinder (with where necessary). Oxygen tubing_ Automated external defibrillator (AED) (Preferably with facilities for paediatric use as well as use in adults). Adhesive defibrillator (Spare set also recommended): Razor. Stethoscope: Absorbent towel (To dry chest if necessary)_ All organisations providing primary care should also have appropriate equipment and drugs for managing other
-threatening emergencies (e.g. anaphylaxis). The CCG would expect all GP staff to be trained to deliver basic CPR to patients, to have this training updated on regular basis and have appropriate protocols in place to deal with such emergencies The CCG has a programme of contract visits where we will ensure that practices are adhering to the guidance provided above Birmingham South Central Clinical Commissioning Group Tel: 0121 255 0863 Email: infobsc@nhsnet Chair: Dr Andrew Coward Vice-Chair: Denise Plumpton Clinical Vice Chair: Dr Raj Ramachandram key pads life-=

In respect of suction being available; the CCG view would be that there would be no requirement for GP practices to have suction available on a regular basis since the use of such equipment would be extremely rare and it would be difficult for GPs to maintain their competence in using this type of equipment; Similarly the CCG would not expect a GP to be able to intubate a patient or to have the equipment available to undertake this procedure as this would not be within the regular skill set ofa GP. This view is based on the Resuscitation Council (UK) guidance that identifies these equipment and competencies are required for GPs having an extended role in aspects such as urgent and emergency care rather than generic general practice: The CCG has been assisting the practice involved in this incident to identify and address issues that have been highlighted by this unfortunate incident and it is the intention of the CCG to circulate any learning from this incident across all GP practices that we are responsible for commissioning: We will also circulate this learning to surrounding CCGs so that may also disseminate these lessons to their practices If you have any queries regarding the above please do not hesitate to call me or e-mail me_