Source · Prevention of Future Deaths

Jackson Chadd

Ref: 2014-0137 Date: 24 Mar 2014 Coroner: Karen Henderson Area: Surrey Responses identified: 2 / 3 View PDF

Concerns include inadequate supervision for junior paediatric staff, insufficient consultant oversight for out-of-hours admissions, failure to apply national guidelines for fever in children, and disregarding parental concerns.

Date 24 Mar 2014

56-day deadline 27 May 2014

Responses identified 2 of 3

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

View full coroner's concerns

RT3934

RT3934
1. Lack of effective supervision of a non-career grade paediatrician with no previous experience
2. Lack of consultant supervision of ‘out of hours’ on-call paediatric trainees
3. Lack of independent consultant assessment of paediatric admissions into Frimley Park Hospital outside normal working hours
4. Lack of effective application of national guidelines for assessment and investigation of fever in children less than one year of age
5. Failure to acknowledge or act on the concerns of a parent

Responses

2 respondents

Frimley Park Hospital NHS / Health Body

26 Mar 2014 PDF

Action Taken

The Hospital updated sepsis guidelines to include tachycardia, changed practices to fast track children with PEWS scores of less than 4 to the Paediatric Assessment Unit, and now requires blood gases on all children presenting with fever or non-blanching rash; it also reiterates its philosophy of 'patient not to go home'. (AI summary)

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Committed To Excellence Working Together Facing The Future Frimley Park Hospital [HS] NHS Foundation Trust Frimley Park Hospital NHS Foundation Trust Response to Regulation 28 Report for HM Coroner for Surrey Re: Jackson CHADD Background Trust received a Regulation 28 Report, Action to Prevent Future Deaths, from HM Coroner for Surrey, dated 26 March 2014_ The Coroner had found the cause of death to be: 1a) Septic shock due to fulminant meningococcal infection The Inquest concluded that the deceased died from fulminant meningococcal septicaemia where the evolving nature of his illness was not recognised or treated. The Coroner was advised that Jackson was a fit and healthy baby until he became unwell at home on 6 August 2012. He was irritable, not feeding well, crying with a temperature, tachycardia (160 bpm) and a raised respiratory rate (>60) took the advice of her GP to go to A&E with possible diagnosis of her son having sepsis. Jackson was triaged in A&E at 5 p.m , found to have a high temperature and a raised heart rate and respiratory rate: He was given paracetamol for his temperature: He was reviewed by the A&E team who referred him to the Paediatricians with a possible diagnosis of sepsis: He was then seen at approximately
p.m. by a non-career ST2 (GP trainee) paediatrician who had been in post for one week with no previous paediatric experience. Some tests were initiated for sepsis. A discussion was had between the ST2 and the Paediatric SpR who, for unknown reasons, did not review Jackson: Throughout this time in A&E, Jackson continued to have high temperature (>38.5) that did not settle with paracetamol or ibuprofen. His other observations were variable but remained abnormal or at the upper limits of normal: No blood pressures were carried out after an attempt at triage failed: During his time in A&E, Jackson had a number of bouts of severe, foul smelling diarrhoea and developed generalised maculo-papular rash with at least 2-3 noticeable non-blanching spots. He was seen by the on-call SpR for the first and only time at 23.30,7 hours after arriving in A&E Jackson was discharged with a diagnosis of gastroenteritis. No significance was placed on the rash or the non-blanching spots. There is a conflict between his mother's belief of how unwell her son was (floppy, pale and lethargic with no obvious signs of improvement) and that of the SpR (smiling, not floppy etc) and she was unhappy that Jackson was not admitted Jackson was taken home but his condition deteriorated and his parents brought him back at or around 0200 where he was found to be in septic shock Despite aggressive resuscitation, Jackson was certified dead at 06.05 on 7 August
2012. Coroner's Concerns Lack of effective supervision of a non-career grade paediatrician with no previous experience In Place at Time of Incident During working hours there are a minimum of 2 Consultant Paediatricians available within the Trust; 1 dedicated to Neonates and the other to Paediatrics and acute admissions with one consultant on-call and resident until 9 p.m: All junior doctors, including SHO level have a Consultant Clinical Supervisor and an Educational Supervisor and are required to maintain portfolios of their development: 2 of 8 The

Committed To Excellence Working Together Facing The Future Military trainees have Trust appointed Consultant Clinical Supervisor and military appointed Educational Supervisor. They have regular formal appraisals with their supervisor and there is on-going shop-floor appraisal: This is in line with the requirements of both the HEKSS & Military Deaneries and at the last review of the Paediatric service in November 2010 was noted to meet their standards. There is an identified College Tutor lead within the Paediatric Department All new SHOs to the Paediatric team will undergo a 3-day induction programme, 1 Corporate Induction plus 2 days local Paediatric Induction: A copy of the Paediatric Induction programme for August 2014 is attached. In addition to this, there is a programme of Paediatric SHO Teaching which covers a variety of subjects including 'Recognition & Management of the Sick Child' and 'NICE an approach to fever in children' (copies of the programme attached): There is no annual leave for Middle Grade doctors over the induction period for SHOs Middle Grade doctors do not attend Paediatric Out Patient Clinics during the induction period for SHOs to ensure they are available to support the junior doctors during this period Paediatric handover takes place 3 times at shift changes and are expected to be supervised by a Consultant during the week and one consultant supervised handover at the weekend at 9.00 a.m;, in line with Facing for the Future Actions Taken Post Incident Review Since the death of Jackson, there are always 2 Middle Grade doctors on 24/7 with a Paediatric Registrar available in the Emergency Department 9 a.m. to 5 p.m: Monday to Friday Further Action Taken Post Coroners' Inquest In place at the time of Jackson'$ death there was an Escalation Policy whereby if a child was in the A&E Department for more than 3 hours waiting for Paediatric opinion, the Consultant should be informed: The SHO should now notify the Consultant if there is more than an hour in senior review of a child.
2. Lack of consultant supervision of 'out-of-hours' on-call paediatric trainees In Place at Time of Incident There is consultant presence in the Trust until 9 p.m. on weekdays, on-call after 9 p.m. with a consultant available from 8.30 a.m_ to
p.m: at weekends: Outside of these hours Consultant Paediatrician is on-call and expected to be able to return immediately if required: This is standard practice in a District General Hospital: There is clear expectation of the junior doctors that patients are discussed with consultants with a low threshold of concern: Since the death of Jackson, a new Emergency Department Paediatric Consultant has been appointed Actions Taken Post Incident Review There is a Consultant responsible for Paediatric A&E working alongside an A&E consultant with a Paediatric interest to supervise junior medical staff Further Action Taken Post Coroners' Inquest Further work is considered by the Trust to strengthen Paediatric Consultant delivered service in moving towards 24/7 cover in line with the Keogh Standards: 3 of 8 day day duty delay being

Committed To Excellence Working Together Facing The Future Lack of independent consultant assessment of paediatric admissions in Frimley Park Hospital outside normal working hours In Place at Time of Incident In April 2011, the RCPCH published 'Facing the Future: Standards for Paediatric Services' which outlined Together for Child Health' which includes the following criteria for review by a consultant: Every child or young person who is admitted to a paediatric department with an acute medical problem is seen by a consultant paediatrician within the first 24 hours. At the last national audit of compliance with this criteria, the Trust scored 100% At least one medical handover in every 24 hours is led by a paediatric consultant (or equivalent): At the last national audit of compliance with this criteria, the Trust was deemed to be compliant with this standard with 3 handovers on weekdays and one handover at weekends Actions Taken Post Incident Review The Trust is currently working to 14 hours for a consultant paediatrician review for every child or young person who is admitted to a Paediatric department with an acute medical problem Lack of effective application of national guidelines for assessment and investigation of fever in children less than one of age In Place at Time of Incident At the time of the incident, the Trust followed the NICE Clinical Guideline 160 on Feverish Illness in Children which are available on the Paediatric section of the Trust intranet As part of the Induction process in Paediatrics, new medical staff are advised on where these can be accessed: Sepsis is part of the induction programme in the first month of starting within Paediatrics As noted under section 1,there is a programme of Paediatric SHO Teaching which includes a specific session on the application of the fever guidelines If Jackson had been recognised as a seriously sick child, this would have been escalated to a consultant immediately Actions Taken Post Incident Review AIl children under the age of 1 with a PEWS score of less than 4 are now fast tracked to the Paediatric Assessment Unit based on the Paediatric Ward for review Sepsis Guidelines have been updated to include tachycardia as per 2013 NICE Further Action Taken Post Coroners' Inquest The Paediatric SHO is to notify the consultant if there is more than an hour before senior review of a child The Emergency Department uses a Paediatric Early Warning Score (PEWS) which must now include a blood pressure reading when scoring every child Blood gases are to be done on all children presenting with a fever or non-blanching rash AIl children presenting with non- blanching rash are to be admitted and treatment considered The implementation of the Fever Guidelines is to be audited of 8 year

Committed To Excellence Working Together Facing The Future Failure to acknowledge or act on the concerns of a parent The Paediatric philosophy of 'patient not to go home' has a low threshold at FPH and has been reiterated to all the junior doctors The SpRs receive 'Parental Concern' as part of their training Conclusion At the time of Jackson's death, there was clear framework in place for the induction and supervision of junior doctors in training, arrangements for consultant assessment of paediatric admissions as well as implemented guidelines for the assessment and investigation of children with a fever: However, it is recognised that on this occasion the processes in place were not followed and we failed to recognise how seriously ill Jackson was_ To strengthen the Paediatric service, changes in practice were made both at the time of the incident review and since the Coroner's Inquest into Jackson's death: Further work is being considered by the Trust to strengthen a Paediatric Consultant delivered service in moving towards 24/7 cover in line with the Keogh Standards and with the aim of prompt intervention and treatment of the acutely ill child. Prepared by: Clinical Director Paediatrics Governance Manager May 2014 5 of 8 happy

Royal College of Paediatrics Child Health Education

20 May 2014 PDF

Action Planned

The RCPCH refers to existing guidance, standards and reports regarding supervision and training and notes their current review of standards to encourage higher levels of consultant supervision. (AI summary)

View full response

Dear Dr Henderson Jackson CHADD (deceased) Regulation 28 Action to Prevent Future Deaths have read carefully your notification above, and discussed this with senior colleagues within the RCPCH in order to respond to your request for details and timescale for action to be taken. The matters of concern listed are as follows: Lack of effective supervision of a NCG Paediatrician 2 Lack of consultant supervision of out of hours on-call paediatric trainees Lack of independent consultant assessment of paediatrics admissions into FPH outside normal working hours Lack of effective application of national guidelines for assessment and investigation of fever in children less than
5. Failure to acknowledge or on the concerns of a parent Given that we do not have all the details of the case presented the RCPCH is unable to comment on the specifics of the case. We have presumed that the hospital Trust will be responding on local policies and procedures and their implementation relating to the above, and will be reviewing and addressing any issues pertaining to the personal practice and competence of the staff involved_ am pleased to set out below the standards of care that we would expect the work that is in progress to develop further guidance in the areas where RCPCH can make a difference Medical Royal Colleges background Medical Royal College are membership-based professional bodies which set the standards for training of specialist doctors in some or all parts of the UK and also contribute to development of professional practice and service standards. All medical consultants in the UK are required to pass professional examinations in their chosen specialty to maintain competence on a specialist register including revalidation and continuous professional development; subject to approval by the General Medical Council (GMC) which regulates the professions_ Alongside setting standards for doctors, Medical Royal Colleges, and their affiliated specialty groups, provide expert clinical input to development of service and clinical standards. In England 2cl #V act and

the most widely recognised guidelines and standards are developed by the National Institute for Health and Care Excellence (NICE) which has a rigorous and systematic process for topic selection, identifying evidence, evidence synthesis, development;, consultation, and final production. Standards are developed in collaboration with expert clinical groups and stakeholders such as medical Royal Colleges and, as could be expected, demand for new guidelines greatly exceeds the capacity of NICE to develop them. NHS bodies and individual clinical departments are expected to ensure that their operational activities comply with NICE guidelines alongside service standards developed by professional bodies such as RCPCH There should be in place in all NHS organisations clear systems and processes for clinical governance which monitor and audit practice and outcomes and design programmes of on-going clinical training for staff. These arrangements should ensure that clinicians remain familiar with the guidance relevant to the cases with which are presented: Paediatric service and supervision standards: This case is one of four recent coroners' cases which have come t0 my attention, three of which have been referred to me under Regulation 28,and two of which have been referred also to the Secretary of State. Whilst there were different factors relevant to each of the cases, there are also common themes, and believe it is important to consider the cross cutting issues in order to respond to best effect: The points which, to a greater or lesser degree, cross all cases are as follows: Adequate training of all healthcare professionals dealing with children Appropriate clinical decision support for healthcare professionals dealing with children Adequate consultant supervision of junior doctors dealing with children: In this tragic case , we have linked your matters of concern to relevant standards and guidance in order t0 set out our action. Items 1-3 relate to clinical supervision and availability of senior advice, for which the 'Facing the Future' standards (RCPCH 2011) apply as well as the 'Standards for CYP in Emergency Care Settings (RCPCH Intercollegiate 2012) Item 4 relates to the NICE 'Fever guidance' , CG160 which replaced CG47 in May 2013. Item 5 is, in our opinion, a local matter for response by the Trust: Facing the Future and emergency care standards (Items 1-3) This document sets out ten standards for paediatric services, mostly based around acute settings_ It can be found on WW rcpch ac uklfacingthefuture and a summary of the standards is attached below: The pertinent standards for Jackson'$ case would be Standard 1 children admitted are seen by a middle grade or above within 4 hours_ Standard 2 _ children admitted are seen by a consultant or equivalent within 24 hours Standard 3 children referred are seen by a consultant, middle grade or suitably experienced nurse In Jackson's case it appeared t0 take seven hours for him to be seen by a middle grade doctor from arrival at the emergency department; but since Jackson was discharged and not admitted standard 2 did not come into play: Standard 8 on page 19 of the Emergency Care standards states that 'systems are in place to ensure safe discharge of children or young people including advice to families on when and where they

to access further care if necessary' The definition of 'safe discharge is not provided but many units have local policies in place that require consultant-led discharge of babies under 12 months of age_ The 'Facing the Future' standards were audited in 2012 by RCPCH for compliance by units across the UK We found standard was met by 77.4% of units and standard 2 by 87.7%
99.2% met standard 3. Although this case may have been compliant with our existing standards, our audit report indicated that we were proposing to reconsider standard 2 amongst others with a view to increasing the frequency of consultant review to twice rather than once in 24 hours This review has now commenced and will take around three months during which we will be collating any evidence available to support the recommendations made. In parallel have discussed this matter with Professor Reid at Health Education England, and as a result our workforce team is working with HEE to model the implications for medical staffing across the country were we to recommend twice daily consultant review: Although it is clear that some children would still slip through the net; even with twice daily consultant review, some parts of the country and some other specialties have already set this as an expected standard of care. In the current environment where there is an increasing emphasis on consultant-delivered care , believe we have to say first and foremost what we consider to be safest practice, albeit recognising that implementation may require considerable changes to staffing and or models of care. NICE fever guidance At the time of Jackson's death, the NICE fever guidelines were in place as CG47 , but have since been updated to CG160 to provide greater clarity on warning signs and actions required to identify serious illness in children: NICE has produced a number of implementation tools and trusts are encouraged to ensure that these guidelines are followed and adherence audited through clinical governance processes_ It s not clear from your summary the extent to which this was done by the Trust in Jackson'S case Why Children Die Earlier this month RCPCH and NCB launched a joint report children die' hltp IwWW rcpch ac uklindex php?9-child-healthlstandards-carelhealth-policylchild-mortalitylchild mortality This examines some of the possible reasons for the relatively high number of avoidable baby and child deaths in the UK and provides in Part B a policy response of recommendations for remedial action which include the following: Better training for healthcare staff AIl frontline health professionals involved in the acute assessment of children and young people should utilise resources such as the 'Spolting the sick child' web resource and complete relevant professional development so they are confident and competent to recognise a sick child Clinical teams looking after children and young people with known medical conditions make maximum use of tools to support improved communication and clarity around on-going management; for example: introduction of epilepsy passports or asthma management plans where appropriate; cooperating with schools to meet their duty to support pupils with medical conditions Whilst recognising that some children still fall through the net; we are of the view that a higher level of consultant supervision should be encouraged and are reviewing our standards accordingly: 'Why will

This is also in line with the various 7-day consultant working documents" and our wn report on consultant-delivered care" RCPCH has a policy priority to focus on reducing child death and we will continue to work with NCB and other partners to press for continued action in this important area_ trust this provides you with the reassurance that RCPCH is working hard t0 minimise the likelihood of recurrence of what Jackson's has faced; thank you for raising this important case and reminding us of the importance of this work:

Report sections

Investigation and inquest

On 20th March 2014 I commenced an investigation into the death of Jackson J Chadd, 5 months of age. The investigation concluded at the end of the inquest on 20th March 2014. The medical cause of death given was: 1a. Septic shock due to fulminant Meningococcal infection 1b. 1c
2. My narrative conclusion was: Jackson J Chadd died from fulminant meningococcal septicaemia where the evolving nature of his illness was not recognised or treated

Circumstances of the death

Jackson was a fit and healthy baby until he became unwell at home on the 6th August 2012. He was irritable, not feeding well, crying with a temperature, tachycardia (160 bpm) and a raised respiratory rate (>60).

took the advice of her GP to go to A&E with a possible diagnosis of her son having sepsis. Jackson was triaged in A&E at 5pm, found to have a high temperature and a raised heart rate and respiratory rate. He was given paracetamol for his temperature. He was reviewed by the A&E team who referred him to the paediatricians with a possible diagnosis of sepsis. He was then seen at approximately 7pm by a non-career ST2 (GP trainee) paediatrician who had been in post for one week with no previous paediatric experience. Some tests were initiated for sepsis. A discussion was had between the ST2 and the paediatric SpR who, for unknown reasons, did not review Jackson. Throughout his time in A&E, Jackson continued to have a high temperature (>38.5) that did not settle with paracetamol or ibuprofen. His other observations were variable but remained abnormal or at the upper limits of normal. No blood pressures were carried out after an attempt at triage failed. During his time in A&E Jackson had a number of bouts of severe foul smelling diarrhoea and developed a generalised maculo-papular rash with at least 2-3 noticeable non-blanching spots. He was seen by the on call SpR for the first and only time at 23.30, 7hrs after arriving in A&E. Jackson was discharged with a diagnosis of gastroenteritis. No significance was placed on the rash or the non-blanching spots. There is a conflict between his mother’s belief of how unwell her son was (floppy, pale and lethargic with no obvious signs of improvement) and that of the SpR (smiling, not floppy etc) and she was unhappy Jackson was not admitted. Jackson was taken home but his condition deteriorated and his parents brought him back at or around 0200 where he was found to be in septic shock. Despite aggressive resuscitation Jackson was certified dead at 06.05 on 7th August 2014. He had two sets of vaccination with the third (delayed by a month by a cold) arranged for the day after his death.

Action should be taken

In my opinion action should be taken to prevent future deaths and I believe you and your organisation: Frimley Park Hospital NHS Trust, Royal College of Paediatrics, and the Secretary of State for Health have the power to take such action.

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Shared signals

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Report details

Reference: 2014-0137
Date of report: 24 March 2014
Coroner: Karen Henderson
Coroner area: Surrey

Responses identified

Responses identified 2 of 3

1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 27 May 2014.

Sent to

Department of Health and Social Care

Frimley Park Hospital

Royal College of Paediatrics and Child Health

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.