Marc Poole
Action Taken
The Trust reviewed the Paediatric IPOC to ensure better communication with parents about a child's clinical history, particularly for children with disabilities. They also revised the Sepsis Recognition and Management Pathway for children, including training for staff and updated equipment, and implemented a 'Red Flag Sepsis' poster for use by all staff. (AI summary)
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Dear Ms Mundy RE: Marc Jason Stephen Poole (Deceased) D.O.B: 29 September 2008 D.O.D: 18 2015 Thank you for your letter of 8 February 2016 addressed to Mr Mike Pinkerton, Chief Executive, Doncaster & Bassetlaw NHS Foundation Trust. With respect to the concluded inquest on Marc Jason Stephen Poole the Regulation 28 report dated 2 February 2016, highlighted a number of concerns and would wish to take the opportunity to address these in the order that they have been listed. have been assisted in the course of this by Matron Andrea Bliss and Mr Eki Emovon, Clinical Director, Children and Family Care Group. Rclis May
1. Poor communication on a number of levels With respect to the discussion with the parents regarding a child' s clinical history, in order to ensure better communication the team have reviewed the Paediatric IPOC. Staff have been made aware of the need to listen to parents and take their views into consideration when assessing the clinical picture in any child who is admitted. Should children suffer from disabilities, medical and nursing staff will record, under the respective part of the Paediatric IPOC, how such children are communicated with and whether their disability further impedes their ability to communicate with strangers and hence the need to have more detailed and in depth conversations with parents. This situation will continue to pertain throughout the child's stay in hospital: With respect to ineffective communication of microbiology results, the team has considered the issue of outstanding test results and confirmed that during clinical handovers the results should be accessed through ICE: outstanding matters will form part of the documentation in the handover process in order to confirm that they are followed up and acted upon. In respect of receipt of urgent blood results from the laboratory via telephone, staff have been made aware that it is the responsibility of the individual taking the call to record the results on the IPOC and to verbally share the results with the medical staff as well as date, time and sign the entry and record the member of medical staff that the results have been shared with. 2 PAWS (Paediatric Advanced Warning Score) Staff have been made aware that at the inquest it was highlighted there were a number of poorly completed charts with incomplete scores during the episode of care: It was the case that temperature readings had been recorded without a corresponding record of the heart rate and respiratory rate being undertaken at the same time which will enable significance to be attached to the result and correctly identify scores: additional training needs for staff have been noted and are in process of being addressed. It is to be noted that all paediatric warning scores within the region are reviewed as part of the network of the Paediatric Operation and Delivery Network led by the Network Clinical Educator and the team will ensure that any developments with respect to PAWS will be filtered down to front line staff in order to continue to maintain and accurate marker of the condition of a sick child.
3. Sepsis in Paediatrics The inquest noted that there was lack of use of the sepsis tool kit and this is of significant concern both to your office as well as the Trust. Since the outcome of the inquest the Trust has worked rapidly to introduce such a tool based on the UK Sepsis Trust tool to which there has been both nursing and medical contribution: attach the tool which has been agreed, implemented and disseminated in all the clinical Any Any being
areas: Multi-disciplinary staff development will continue to provide training on sepsis in children and unexpected deterioration in children. This training will include medical staff on induction for each house_
4. Dissemination of key information and medical updates The Trust has reviewed its systems for disseminating such information: The Sepsis tool kit was disseminated and implemented for adults but for some reason this was not achieved in paediatrics The revised process involves such information being received by the Patient Safety Review Group (PSRG) and then disseminated through members of the group to the relevant areas where the information or update is relevant: The PSRG will monitor that guidance has been implemented. The Trust Sepsis Lead has undertaken to support the Paediatric team with monitoring of the implementation of the Sepsis tool. 5 Poor record keeping It is acknowledged that record keeping was poor both from medical and nursing staff and | confirm the individuals who were involved in this case have reflected on this and the importance of recording care that is given to patients_ Staff have been reminded that record keeping is in line with what is expected by the Nursing and Midwifery Council and the General Medical Council Guidelines on record keeping: In respect of this all Consultants within the Trust are required to undertake an audit of clinical records as part of their yearly appraisal. You would be interested to note that there have been the following immediate changes to practice:
1. In all instances the minimum recording on PAWS includes temperature measurement; pulse and heart rate measurement as well as frequency of respirations. This is documented together with the child'$ colour at the time that such observations have been undertaken. skin change such and pallor, mottling or rash is documented on the PAWS chart and a minimum temperature pulse and respiratory rate performed at that particular point in time_ 3_ The PAWS score is documented for each individual observation and then totalled. observations will be documented directly onto the PAWS chart: Staff have been made aware of these changes in practice and have been required to complete a self-declaration form. This allows opportunity for individuals to inform the Line Manager if require additional training relating to observations and PAWS. Each Healthcare Assistant is also asked to complete a self-declaration form indicating that they were competent to undertake and document physiological observations and to report to a Registered Nurse any observations/PAWS outside of normal parameters. Each Registered Nurse has been asked to complete a self- good Any Any they
declaration to indicate that were competent to undertake document and interpret physiological observations and able to report to medical staff any observations/PAWS outside of normal parameters trust that this will provide assurance that appropriate action has been taken following the death of Marc Jason Stephen Poole: The changes will continue to be monitored by the Care Group Clinical Governance team and Patient Safety Review Group May take this opportunity to invite you to revert back to me should you feel it necessary to do so_ Yoursisincerely Deputy Medical Director Clinical Standards es they
Doncaster and WS Paediatric Sepsis Screening and Action Tool Bassetlaw Hospitals NAS Foundation Trust Sepsis is a time critical condition. Screening, early intervention and immediate treatment save lives. This tool should be applied to all children with suspected infection or who have observations outside normal limits_ 1 , Could this be an infection? Sepsis not present now: Observe and review as per clinical need. For example: Pneumonia Urinary Tract Infection Abdominal pain or distension Sepsis considered Inform responsible clinician. Meningitis Begin hourly observations_ Cellulitis/ septic arthritis/ infected wound Reassess for severe sepsis hourly Ensure FBC , CRP U&E, LFT BM; venous blood gas with lactate & blood cultures sent; 2 Are any 2 Systemic inflammatory response Monitor urine output: syndrome (SIRS) criteria present Temperature
38.50C or < 360C Inappropriate tachycardia or bradycardia When to consider observations Altered mental status (including sleeping/ abnormal: irritability/ lethargyl floppiness Tachycardia Bradycardia Hypotension systolic BP Reduced peripheral perfusion/ prolonged days [0 week 180 00 <65 capillary refilll reduced urine output or wet nappies week t0 morth >180 <i00 <75 month [0 year 180 <90 100 2-5 years >140 NA <94
3. Is any one Red present? 6-|2yrs >130 NA 105 Hypotension 13 t0 18 years >0 NA Blood gas lactate > 4 mmoll Capillary refill > 5 seconds Palel mottled/ ashen/ blue or non-blanching Red Sepsis rash This is a time critical condition Oxygen needed to maintain saturations >92% Take bloods as mentioned in the box Respiratory rate 60 min-1 or > 5 below the Sepsis considered. Assume severe normal, or grunting sepsis present: AVPU = V,P or U Paediatric Sepsis Six: Parents report one of: High-flow oxygen. excessively dry nappies, lack of response to 2 Take cultures. glucose, FBC , lactate, CRP social cues, significantly decreased activity, or 3 Intravenous or intraosseous antibiotics weak; high-pitched or continuous cry 4 Fluid resuscitation (2Omllkg) 5 Involve senior clinicians early 6 Consider inotropic support early THEUK This tool is developed original work of the UK Sepsis Trust: The Paediatric Record the time each of these actions iS SEPSIS Sepsis Six Paediatric Red Flag Sepsis completed. All actions should be completed are the intellectual property of the UK TRUST Sepsis Trust as soon as possible but always within 60 minutes Flag Flag fromn and
1. Poor communication on a number of levels With respect to the discussion with the parents regarding a child' s clinical history, in order to ensure better communication the team have reviewed the Paediatric IPOC. Staff have been made aware of the need to listen to parents and take their views into consideration when assessing the clinical picture in any child who is admitted. Should children suffer from disabilities, medical and nursing staff will record, under the respective part of the Paediatric IPOC, how such children are communicated with and whether their disability further impedes their ability to communicate with strangers and hence the need to have more detailed and in depth conversations with parents. This situation will continue to pertain throughout the child's stay in hospital: With respect to ineffective communication of microbiology results, the team has considered the issue of outstanding test results and confirmed that during clinical handovers the results should be accessed through ICE: outstanding matters will form part of the documentation in the handover process in order to confirm that they are followed up and acted upon. In respect of receipt of urgent blood results from the laboratory via telephone, staff have been made aware that it is the responsibility of the individual taking the call to record the results on the IPOC and to verbally share the results with the medical staff as well as date, time and sign the entry and record the member of medical staff that the results have been shared with. 2 PAWS (Paediatric Advanced Warning Score) Staff have been made aware that at the inquest it was highlighted there were a number of poorly completed charts with incomplete scores during the episode of care: It was the case that temperature readings had been recorded without a corresponding record of the heart rate and respiratory rate being undertaken at the same time which will enable significance to be attached to the result and correctly identify scores: additional training needs for staff have been noted and are in process of being addressed. It is to be noted that all paediatric warning scores within the region are reviewed as part of the network of the Paediatric Operation and Delivery Network led by the Network Clinical Educator and the team will ensure that any developments with respect to PAWS will be filtered down to front line staff in order to continue to maintain and accurate marker of the condition of a sick child.
3. Sepsis in Paediatrics The inquest noted that there was lack of use of the sepsis tool kit and this is of significant concern both to your office as well as the Trust. Since the outcome of the inquest the Trust has worked rapidly to introduce such a tool based on the UK Sepsis Trust tool to which there has been both nursing and medical contribution: attach the tool which has been agreed, implemented and disseminated in all the clinical Any Any being
areas: Multi-disciplinary staff development will continue to provide training on sepsis in children and unexpected deterioration in children. This training will include medical staff on induction for each house_
4. Dissemination of key information and medical updates The Trust has reviewed its systems for disseminating such information: The Sepsis tool kit was disseminated and implemented for adults but for some reason this was not achieved in paediatrics The revised process involves such information being received by the Patient Safety Review Group (PSRG) and then disseminated through members of the group to the relevant areas where the information or update is relevant: The PSRG will monitor that guidance has been implemented. The Trust Sepsis Lead has undertaken to support the Paediatric team with monitoring of the implementation of the Sepsis tool. 5 Poor record keeping It is acknowledged that record keeping was poor both from medical and nursing staff and | confirm the individuals who were involved in this case have reflected on this and the importance of recording care that is given to patients_ Staff have been reminded that record keeping is in line with what is expected by the Nursing and Midwifery Council and the General Medical Council Guidelines on record keeping: In respect of this all Consultants within the Trust are required to undertake an audit of clinical records as part of their yearly appraisal. You would be interested to note that there have been the following immediate changes to practice:
1. In all instances the minimum recording on PAWS includes temperature measurement; pulse and heart rate measurement as well as frequency of respirations. This is documented together with the child'$ colour at the time that such observations have been undertaken. skin change such and pallor, mottling or rash is documented on the PAWS chart and a minimum temperature pulse and respiratory rate performed at that particular point in time_ 3_ The PAWS score is documented for each individual observation and then totalled. observations will be documented directly onto the PAWS chart: Staff have been made aware of these changes in practice and have been required to complete a self-declaration form. This allows opportunity for individuals to inform the Line Manager if require additional training relating to observations and PAWS. Each Healthcare Assistant is also asked to complete a self-declaration form indicating that they were competent to undertake and document physiological observations and to report to a Registered Nurse any observations/PAWS outside of normal parameters. Each Registered Nurse has been asked to complete a self- good Any Any they
declaration to indicate that were competent to undertake document and interpret physiological observations and able to report to medical staff any observations/PAWS outside of normal parameters trust that this will provide assurance that appropriate action has been taken following the death of Marc Jason Stephen Poole: The changes will continue to be monitored by the Care Group Clinical Governance team and Patient Safety Review Group May take this opportunity to invite you to revert back to me should you feel it necessary to do so_ Yoursisincerely Deputy Medical Director Clinical Standards es they
Doncaster and WS Paediatric Sepsis Screening and Action Tool Bassetlaw Hospitals NAS Foundation Trust Sepsis is a time critical condition. Screening, early intervention and immediate treatment save lives. This tool should be applied to all children with suspected infection or who have observations outside normal limits_ 1 , Could this be an infection? Sepsis not present now: Observe and review as per clinical need. For example: Pneumonia Urinary Tract Infection Abdominal pain or distension Sepsis considered Inform responsible clinician. Meningitis Begin hourly observations_ Cellulitis/ septic arthritis/ infected wound Reassess for severe sepsis hourly Ensure FBC , CRP U&E, LFT BM; venous blood gas with lactate & blood cultures sent; 2 Are any 2 Systemic inflammatory response Monitor urine output: syndrome (SIRS) criteria present Temperature
38.50C or < 360C Inappropriate tachycardia or bradycardia When to consider observations Altered mental status (including sleeping/ abnormal: irritability/ lethargyl floppiness Tachycardia Bradycardia Hypotension systolic BP Reduced peripheral perfusion/ prolonged days [0 week 180 00 <65 capillary refilll reduced urine output or wet nappies week t0 morth >180 <i00 <75 month [0 year 180 <90 100 2-5 years >140 NA <94
3. Is any one Red present? 6-|2yrs >130 NA 105 Hypotension 13 t0 18 years >0 NA Blood gas lactate > 4 mmoll Capillary refill > 5 seconds Palel mottled/ ashen/ blue or non-blanching Red Sepsis rash This is a time critical condition Oxygen needed to maintain saturations >92% Take bloods as mentioned in the box Respiratory rate 60 min-1 or > 5 below the Sepsis considered. Assume severe normal, or grunting sepsis present: AVPU = V,P or U Paediatric Sepsis Six: Parents report one of: High-flow oxygen. excessively dry nappies, lack of response to 2 Take cultures. glucose, FBC , lactate, CRP social cues, significantly decreased activity, or 3 Intravenous or intraosseous antibiotics weak; high-pitched or continuous cry 4 Fluid resuscitation (2Omllkg) 5 Involve senior clinicians early 6 Consider inotropic support early THEUK This tool is developed original work of the UK Sepsis Trust: The Paediatric Record the time each of these actions iS SEPSIS Sepsis Six Paediatric Red Flag Sepsis completed. All actions should be completed are the intellectual property of the UK TRUST Sepsis Trust as soon as possible but always within 60 minutes Flag Flag fromn and