Dear Mr Sullivan Tillie Spencer-Adams am writing in response to your regulation 28 report to prevent future deaths, dated 5th September 2019, regarding the above named. was extremely saddened to learn of the circumstances of Tillie's death on 18th June 2018. Lam grateful for you taking the time to meet witt Medical Director, and Clinical Director for Paediatrics, to discuss the regulation 28 report. Whilst know we provided you with a report frond IConsultant Paediatrician; in advance of the Inquest; this was only in relation to the care provided on 18th June It was most unfortunate that my staff were not able to assist you further either prior to the Inquest with a report covering the care provided on 4th 2018 or at the Inquest in person am aware that the post-mortems found Tillie to have sustained fractures to her distal radius and ulna along with an old sub-scalp haemorrhage and old subdural haemorrhage and note that your letter states it is plausible that these happened as a result of the road traffic collision on 4th 2018, The contents of your letter were of grave concern to me and therefore asked Clinical Director for Paediatrics, to review the care provided when Tillie attended on 2018 Tillie was brought in by ambulance at approximately 01.OOhrs; the ambulance sheet records her only injuries to be a reddening to right collar bone On arrival in the Emergency Department she was assessed by the triage nurse who documented the red mark on her clavicle with a red mark on her head and queried some mild swelling to her right eye_ This same Nurse completed an information sharing form in view of Tillie's mother having been found to be driving under the influence of alcohol and on that she noted red mark on right shoulder and head: Tillie was then moved to the Children's Assessment Unit where she was reviewed by a Paediatric Registrar; this review included taking a detailed with a full physical examination; A Zcm linear red mark was found on her right clavicle and documented in the Chief Executive: Mr Nick Carver Trust Chair: Mrs Ellen Schroder May` May May along history along

medical records The medical records specifically state that there was no facial bruising seen and no other bruising noted anywhere else on her body: Tillie's case was discussed with the Paediatric Consultant who advised that there was no requirement for a CT head scan as there was no external visible injury but to admit her for observation. In view of the presenting history, Tillie remained under hourly neurological observation and both the Police and the Trust made a social services referral. Tillie was reviewed by a Paediatric Consultant on the ward round the following morning; This review included a review of the presenting history and events overnight along with a detailed physical examination. The notes from that examination record that she was alert; active, good tone, handling well. The only injury noted is a linear red scratch mark on right mid- clavicular line. She was noted to be a 'well baby' . There was no indication from that review that there were any concerns about either her arm or a head injury At approximately 11am Tillie was transferred from the Children's Assessment Unit to Bluebell Ward The handover document records the only injury to be a red mark on her clavicle. Whilst the triage nurse in ED noted a red mark on Tillie's head, this was not observed by either of the Paediatric doctors who reviewed her_ nor any of the Paediatric nurses In addition; Tillie did not display any red-flag symptoms indicative of a head injury. Thus, in line with NICE Guidance, there was no indication to perform a CT head scan: Equally there were no external signs of any injury to her right forearm, nor did Tillie appear to be in any discomfort whilst in ED or the Paediatric unit. She did not require any analgesia and the medical records indicate that she was settled throughout the admission. Ihas discussed the case with the East of England (EoE) trauma network who agreed that in the absence of clinical concerns_ there were no requirements for this child to be subjected to further imaging or investigations_ For reference suggested referring to the EoE trauma network guidelines which are aligned with The Royal College of Radiologists guidelines for trauma in children. Please find Iinks below; http JlwW eoetraumanetworknhs uklclinicians/trauma-east-manual-of-procedures-and operations http IlwwW eoetraumanetwork nhs ukldocsldefault-sourceltrauma-east-manual-of procedures-and-operationsltempo-05 e-I-emergency-department-paediatric-major-trauma: imaging-decision-tooLpdizsfvrsn-2 Whilst recognise the contents of your regulation 28 report, hope the above explanation assures you that when Tillie attended the Trust on 4th May 2018 she was treated appropriately and in line with national guidance There was no indication to the clinicians at that time that Tillie had any injury to either her forearm or her head. We have stringent clinical governance measures in place to prevent such incidents from_ occurring: Our Paediatric team are committed to providing the best possible care for children and young people in our area and we continually strive to improve the services available_