Source · Prevention of Future Deaths

Millie Elizabeth Thompson

Ref: 2013-0356 Date: 6 Dec 2013 Coroner: John Pollard Area: Manchester (South) Responses identified: 3 / 3 View PDF

Nursery staff lacked sufficient and updated paediatric first aid training. Ambulance call-takers misinterpreted breathing, causing incorrect triage, and emergency vehicles were inadequately equipped with paediatric life-saving kits.

Date 6 Dec 2013

56-day deadline 31 Jan 2014 est.

Responses identified 3 of 3

Other related deaths

Coroner's concerns

AI summary

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_ During the course of the evidence it became apparent that there were only a few members of staff at the_Nursery who had undergone Paediatric First Aid training_and_ 26th day, had the that there is a need for specialist training when confronted with certain medical conditions affecting young children. Other members of staff had general First Aid training but this appears t0 have been less useful in the circumstancege Itzalso transpired that the First Aid certification of some of the staff had lapsed by the passage of time, so that although had undergone the training it now needed updating: The EMD (call-taker) for the Ambulance Trust is a non-medically trained person who simply takes the details and reads from the appropriate 'card" as to what questions should be asked and what advice should be given as well as determining how the is to be triaged and allocated: It appears that because of a misinterpretation case person as to the question of "ineffectiveleffective breathing" the case by that allocated. was wrongly rtook thetview that ALL nursery staff should be subject to mandatory paediatric First Aid training; that there should be better selection and training of Call-Taking staff for the shobudahce service; that ALL emergency ambulances (including rapid responservehicles) should be equipped with suitable paediatric life-saving kit.

Responses

3 respondents

Edward Timpson MP

14 Jan 2014 PDF

Action Planned

The Department for Education acknowledges the concern about paediatric first aid training and states that it is a statutory requirement for early years providers. They are consulting on reinforcing the need for a first-aid trained member of staff to be available at all times and expect to publish the results in February 2014. (AI summary)

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ETNon 2013/0080195ETPO FOR Edward Timpson MP Parliamentary Under Secretary of State for Children and Families Sanctuary Buildings 20 Great Smith Street Westminster London SWIP 3BT tel: 0370 000 2288 WWW. education gov uklhelplcontactus John S Pollard Senior Coroner The Coroner's Court Mount Tabor; Mottram Street Stockport SK1 3PA Your ref: JSPIKA/02333-2012 14 January 2014 Jak, Thank you for your letter of 11 December; addressed to the Secretary of State, enclosing a Regulation 28 Report to Prevent Future Deaths, in relation to the inquest examining the death of Millie Thompson: am replying as the minister responsible for this policy area. Millie Thompson's death, while in the care of Ramillies Nursery in Cheadle Hulme, was a tragedy: note that amongst your concerns about this case that you take the view that all staff working in nurseries should be subject to mandatory paediatric first aid training: The safety of children whilst being cared for by others is of paramount importance and staff with paediatric first aid training should always be available Paediatric first aid training is, and will remain, a statutory requirement for all eariy years providers regulated under the Childcare Act 2006. The requirements for early years providers, including nurseries, are set out in the Statutory Framework for the Early Years Foundation Stage (EYFS): At least one person who a current paediatric first aid certificate must be on the premises at all times when children are present; and must accompany children on outings. In July 2013 we published plans to further improve the quality and availability of childcare. In tandem with this publication, the Government launched a public consultation, The Regulation of Childcare" , which ran 16 July to 30 September 2013. The consultation sought views on proposals to amend the current childcare regulatory system and set out the measures needed to ensure children's safety. As part of that; we proposed to reinforce the need that a first-aid trained member of staff must be available at all times. 8 Ation 'ARTMENT EDUCE has from

We also proposed to say more in the EYFS about the specific content of suitable courses: We expect to be able to publish the results of the consultation shortly during February 2014 and make any changes needed later this year Yw sinu-} QLd _ Edward Timpson MP Parliamentary Under Secretary of State for Children and Families

North West Ambulance Service NHS Trust NHS / Health Body

22 Jan 2014 PDF

Action Taken

NWAS describes its recruitment and training processes for Emergency Medical Dispatchers (EMDs), including a six-week training course and continuing education requirements. All EMDs are required to undergo CPR recertification every two years. (AI summary)

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Dear Mr Pollard MILLIE THOMPSON (DECEASED) We write further to your letter of 11 December 2013,enclosing a Regulation 28 Report to Prevent Future Deaths in relation to the inquest examining the death of Millie Thompson: Please accept this as our response in accordance with Regulation 29(4). We note that you raise concerns regarding the: selection and training of Emergency Medical Dispatchers (EMDs); and paediatric life saving equipment carried by emergency ambulances. EMDs North West Ambulance Service (NWAS) is acutely aware of the importance of EMDs in relation to the care of patients_ We have robust, competitive recruitment process for EMDs, attracting approximately 300 applications for each vacant post_ We continually review this recruitment and assessment process with the aim of ensuring only the most suitable and able candidates are appointed for this demanding and important role All EMDs undergo a six week training course, covering policies and procedures, the call taking processes, first aid, including paediatric resuscitation, and use of the Advanced Medical Priority Dispatch System (AMPDSI, which includes the ineffective breathing diagnostic tool: Successful completion of the course results in an internationally recognised qualification. In order to maintain their certification, EMDs must provide proof of continuing education and evidence of audit review, which provides safeguard to ensuring their continuing competence in the role: are also required to undergo CPR recertification every two years. 'adquarters: Ladybridge Hall, 399 Chorley New Road, Bolton. BL1 SDD Iairman: Mrs M Whyham MBE AAVLSTS ief Executive: Mr B Williams INT'FOPIE LlampIOn W Delivering the right care, at the right time, in the right place They JovI _

Department of Health Central Government

PDF

Noted

The Department of Health acknowledges the concerns, notes that training of nursery staff is the DfE's responsibility and NWAS is responsible for selection/training of call takers. They report that NWAS vehicles are equipped with paediatric equipment and they will share the report with the Association of Ambulance Chief Executives. (AI summary)

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From the Rt Hon Jeremy Hunt MP Secretary of State for Health Department of Health Richmond House 79 WVhitehall POCI_829927 London SWIA 2NS Mr John Pollard Tel: 020 7210 3000 Senior Coroner Mb-sofs@dhgsi-gov.uk Coroner'$ Court Mount Tabor Mottram Street h FK; 2016 Stockport SKI 3PA Je A.e.Ile4, Thank you for your letter following the inguest into the death of Millie Thompson: In your report you state that Millie died choking: Millie was fed Shepherds Pie for lunch at the Ramillies nursery and started to choke; She inhaled some of the food which eventually lodged in her left main bronchus_ This led to a tension pneumothorax leading to cardiac arrest which was the underlying cause ofher death; When the call was made to the ambulance service it was wrongly assessed by the call taker meaning that a rapid response vehicle was not despatched, The call taker for the ambulance trust misinterpreted the information relating to effectivelineffective breathing and the case was wrongly allocated. When the ambulance arrived, the oxygen mask that was carried on the vehicle did not properly fit a very young child and so a second ambulance crew had to be called. You raise the following matters of concern and ask that we consider: Only = few of the nursery staff had undergone Paediatric first aid training: You feel it should be mandatory for all nursery staff to take paediatric first aid training; There should be better selection and training of call taking staff at the ambulance trust; All emergency ambulances should be equipped with suitable paediatric life- kit; from being ` saving

Inote that you have sent a copy of this_ Regulation 28 report to the Department for Education (DfE) and the North West Ambulance Service Trust (NWAS) The training ofnursery staff is the responsibility ofDfE whilst the selection and training of call taking staffat the NWAS is a matter for the NWAS Trust: I believe that these two issues should properly be addressed by the DfE and the NWAS. With regard to equipping emergency ambulances with suitable paediatric life- saving kit; this is the responsibility of the individual Ambulance Trust: Officials have however; discussed this issue with colleagues at NWAS and can report that locally, all their emergency response vehicles, both ambulances and response vehicles, are equipped with a range of paediatric emergency equipment as follows: Paediatric oropharyngeal airways Paediatirc Nasopharyngeal airways Layngeal masks Paediatric sized oxygen delivery masks Neonatal and paediatric bag-valve-mask devices for artificial ventilation Paediatric defibrillation Paediatric sized endotracheal tubes Paediatric laryngoscopes Cook IO needles for intra-osseous access (drug/fluid administration) All of the above equipment may be used in the resuscitation of paediatric patients. In addition; we will share this Regulation 28 report, our response and the NWAS response with the Association of Ambulance Chief Executives s0 can consider whether any further action 01 guidance is needed with regard to the equipping of emergency vehicles nationally. I that this response is helpful and am grateful to you for bringing the circumstances of Millie'$ death to my attention. L #1l JEREMY HUNT rapid pads they hope

Report sections

Investigation and inquest

On the October 2012 commenced an investigation into the death of Millie Elizabeth Josephine Thompson_ The investigation concluded at the end of the inquest on 5th December 2013 The conclusion of the inquest was that Millie died from 1a Choking and a conclusion of Misadventure was recorded by the jury._

Circumstances of the death

On the morning of the 23" October 2012 Millie, then aged 9 months, was taken to Ramillies Nursery in Cheadle Hulme, Stockport, Greater-Manchester. This establishment which is registered with OFSTED caters for children from age 6months to 16 years Whilst she was being fed Shepherd's Pie for lunch that she started to choke; she inhaled some of the food which eventually lodged in her left main bronchus, this led to her sustaining a tension pneumothorax leading to the cardiac arrest which was the underlying cause of death. When the call was made to the Ambulance service, the call taker wrongly assessed and allocated it thus meaning that a Rapid Response vehicle was not despatched. The crew of the first ambulance found that the oxygen mask that they on their vehicle did not properly ft a very young child and they had to call for the assistance of a second crew.

Action should be taken

In my opinion action should be taken to prevent future deaths and believe andlor severally, have the power to take such action. you, jointly

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Report details

Reference: 2013-0356
Date of report: 6 December 2013
Coroner: John Pollard
Coroner area: Manchester (South)

Responses identified

Responses identified 3 of 3

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 31 Jan 2014 (estimated).

Sent to

North West Ambulance Service Trust

Department for Education

Department for Health

Source links

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Data: judiciary.uk under OGL.