Independent Patient Safety Investigation report of Yusuf Nazir

Specific & Reasoned: Implement structured reflective practice within supervision to systematically consider differential diagnoses, explicitly addressing cognitive biases.

Measurable & Achievable: Develop audit criteria for medical records to verify inclusion of differential diagnosis by December 2025.

Realistic & Effective: Identify whether the audit has positively impacted on the management of patients by considering how you can measure identification of the outliers, those who have not responded to initial treatment and therefore benefited from an alternative diagnosis.

Specific and Reasoned: Embed consultation skills addressing caregiver concerns within existing departmental education and simulation programmes focused on managing the acutely unwell child.

Measurable and Achievable: Ensure 100% of relevant local training programmes including simulations include clearly defined learning outcomes related to caregiver communication skills and are completed by December 2026.

Realistic and Effective: Enhance clinicians’ skills in managing caregiver concerns improving overall patient and caregiver experience in acute presentations. Integrate this objective within existing educational frameworks, avoiding additional burdens by leveraging current simulation and educational resources.

Specific & Achievable: Introduce structured documentation prompts specifically designed to consistently capture and address parental concerns during clinical and nursing assessments. Implement by June 2026.

Measurable & Timebound: Audit patient records quarterly from June 2026 to confirm structured prompts are routinely completed and actioned effectively.

Specific and Achievable: Conduct a comprehensive review of current workloads for ambulance crews including staff downtime and breaks.

Measurable & Timebound: Complete review and provide a report with actionable recommendations by December 2025.

Specific and Achievable: Implement into your mandatory training programmes Cultural Competence and Civility Saves Lives principles, specifically designed to equip ambulance crews with skills to recognise and respond effectively to diverse cultural needs, while understanding how professional attitudes and behaviours significantly influence patient experience, safety, and include unbiased handovers.

Measurable & Timebound: Evaluate training impact annually through patient feedback surveys and complaint's themes, beginning December 2025.

Specific and Achievable: Develop clear guidelines and patient materials for ambulance staff to communicate effectively with patients regarding their rights to choose care options versus emergency medical priorities.

Measurable & Timebound: Publication of patient materials and their usage reviewed in December 2026.

Specific and Achievable: Undertake comprehensive review and revision of all vascular access and intravenous therapy guidelines, integrating ANTT standards and Vessel Health and Preservation guidance (2020) for clinical decision-making.

Measurable & Timebound: Guidelines revised and disseminated by September 2025.

Specific and Achievable: Identify intravenous therapy and vascular access training building on the guidelines across the trust to enhance governance and clinical safety.

Measurable & Timebound: Standardised training curriculum implemented and evaluated annually, commencing January 2026.

Specific and Achievable: Adopt Device-Related Infection Prevention Practices (DRIPP) audits as regular practice to continually monitor and improve intravenous therapy and vascular access care standards.

Measurable & Timebound: Quarterly auditing implemented from June 2025, with results integrated into continuous improvement actions.

Specific and Achievable: Create and adopt a robust, evidence-based cannula/vascular access insertion guideline, clearly defining ANTT practices, recommended dressing techniques and escalation procedures for difficult insertions.

Measurable & Timebound: Full guideline implementation with staff training completed and audited for compliance by December 2025.

Specific and Achievable: Revise Medicines Management Policy to explicitly acknowledge intravenous therapy as an integral nursing practice, detailing mandatory training and competency assessment requirements across multidisciplinary teams.

Measurable & Timebound: Implementation across trust with measurable compliance by December 2025, evidenced through training audits.

Specified & Achievable: Redesign prescription charts for clarity, ease of prescribing and administration, ensuring compatibility with best practice and consideration of double signature administration requirements. Evaluate feasibility of transitioning to electronic prescribing systems.

Measurable & Timebound: Revised charts implemented and evaluated through staff and prescriber feedback by June 2026, with clear decision timeline for electronic prescribing adoption.

Specific & Achievable: Roll out trust-wide Paediatric Early Warning Score (PEWS) training and ensure clear dissemination and regular reinforcement of escalation pathways, clarifying triggers and responsibility roles.

Measurable & Timebound: Training completed for all relevant multidisciplinary staff by December 2025, followed by annual refresher sessions and audit of compliance and effectiveness.

Specific & Achievable: Establish visible consultant-led oversight for every child for acute wards for handovers and recorded in the medical record.

Measurable & Timebound: This should be achieved by September 2025 and demonstrated through rota compliance.

NIHR commissioned research to quantify the extent to which caregivers feel their concerns have not been addressed following a consultation.

NIHR commissioned research on the association between tonsillitis and secondary infections (including Group A Strep) which may help with designing future guidance on children presenting with tonsillitis.

To ensure families are informed that when their children are on ventilators, they may still be able to hear, and should be encouraged to talk to and interact with them.

To ensure that any items such as clothing or equipment can be saved so families can keep as memories when a child dies.

Explore the development of a national workforce plan to support sustainable consultant oversight across seven-day services, particularly in paediatrics. This should include consideration of realistic models for weekend medical review that balance patient safety, continuity of care, and workforce wellbeing, acknowledging the pressures during high-demand periods such as winter.

Consider national guidance on enabling parents to have appropriate visibility of their child’s medical records during admission, potentially learning from models such as maternity-held notes, to support shared understanding of care plans and promote collaborative decision-making.

Undertake a national review of the continued use of paper-based records in paediatric settings, recognising the impact this can have on continuity and safety.