Source · Investigations in the NHS

Independent investigation report into the care and treatment of Yusuf

North East and Yorkshire Published 01 Sep 2023 Trust Yorkshire Ambulance Service NHS Trust

NHS South Yorkshire commissioned an independent investigation into the death of Yusuf and the care and treatment he received from his first contact with health services on 15 November 2022 . The report makes a number of recommendations for organisations involved in his care and treatment which, while they would not have changed the course of events for Yusuf, should be implemented to ensure there is learning from this case. The independent report can be viewed here. The Rotherham NHS Foundation

Acceptance status

Per recommendation

No Response Published

Total recommendations

About this data

Acceptance status tracks whether the trust accepted or responded to each recommendation.

Independent health investigation reports and reviews commissioned by government or NHS England.

About this investigation

Source & metadata

Independent investigation report. Recommendations and any published response are extracted below.

Recommendations

19 total

Recommendation

At times there was conflict between relatives, paramedic teams and hospital staff while Yusuf’s family attempted to access urgent care. National research should be commissioned to look into why and when parents raise concerns about their children’s acute presentation to … Read more

Recommendation

Yusuf’s mother was expecting to see a GP and not a primary care nurse practitioner when she made an appointment for Yusuf. Patients who make appointments with their GP surgery should be told which healthcare professional they (or their family … Read more

Recommendation

Protocols were appropriately considered in transporting Yusuf to Rotherham Hospital, but there were difficult conversations between Yorkshire Ambulance Service staff and the distressed parents as they sought help from the paramedics for their son who was unwell. This added a … Read more

Recommendation

Difficult conversations took place between relatives and hospital staff as Yusuf’s family attempted to access urgent care. • All clinical teams are to be encouraged to attend simulation communication training on conflict in patient care. • It is advised that … Read more

Recommendation

We did not see evidence of cannula patency17 having been documented and cannot be assured of the quality of cannulation management. The Trust must ensure that all staff giving antibiotics intravenously check the line is unobstructed before each dose and … Read more

Recommendation

Different paediatric observation tools (for example, the Paediatric Observation Priority Score (POPS) and Paediatric Early Warning System (PEWS)) were used by different providers across the care pathway. We are aware of the efforts of NHS England, the Royal College of … Read more

Recommendation

The assessments in primary care could have been more comprehensive (although there was no evidence this impacted the outcome). a. All primary care clinicians who are assessing sick children should have training specific to that assessment, for example, Spotting the … Read more

Recommendation

While they did not affect the prompt access to care, the clinical examinations and physiological observations carried out by the paramedics did not fully comply with local or national guidelines. Essential examinations and physiological observations must be completed and documented … Read more

Recommendation

There were minor recording errors that IT solutions could solve. Namely that the ST6 doctor was still being recorded as a foundation doctor, the child’s height was pulled through from SystmOne16 and the BMI calculations used height/weight (kg), which is … Read more

Recommendation

Yusuf did not have a post-mortem, which has meant there was a missed opportunity to understand his underlying pathology more definitively. • The Trust should review its criteria and decision-making in relation to undertaking hospital post-mortems for children who die … Read more

Recommendation

Parents and relatives raised repeated concerns over time and across providers that his presentation was not his usual self. They took videos and pictures to document his presentation in an attempt to demonstrate their concerns. The history of concerns over … Read more

Recommendation

A functional paediatric pulse oximeter13 was not used when Yusuf attended the GP surgery for his appointment. All practices should have access to age-appropriate equipment, including pulse oximeters, so clinicians can accurately assess sick children when they present. Read more

Recommendation

The administration of oxygen was not in line with national guidance although there was evidence that the amount given did have a positive effect on the patient’s condition. For children who have been assessed as hypoxic, oxygen must be administered … Read more

Recommendation

Medical staffing levels were below expected levels on the night of 15 November. • The Trust should assess medical and nursing staffing levels in the paediatric UECC overnight to ensure capacity meets demand. This should include the number of clinicians, … Read more

Recommendation

A nutritional risk assessment (STAMP) was not completed. The impact of pre-admission reduced nutritional intake was not assessed. • The Trust should ensure the STAMP screening is completed accurately on admission as per Trust policy. • The Trust should review … Read more

Recommendation

There was a lack of clarity in primary care about accessing the opinion of paediatric services at Rotherham Hospital. To avoid future ambiguity, a written protocol should be produced for the agreed pathway and criteria for referring on for further … Read more

Recommendation

Given the clinical findings, a pre-alert should have been sent to the receiving hospital, but this did not take place. Pre-alert protocols must be adhered to so that receiving hospitals can prepare for and respond appropriately to the arrival of … Read more

Recommendation

Staff were unaware of the website resource Healthier Together which contains information leaflets and advice (for safety netting). • Parents should be directed to the Healthier Together website for written patient information. • Nursing and medical staff working in the … Read more

Recommendation