Dear Colleagues, I write to draw your attention to the recommendations of a Serious Case Review undertaken by Lewisham Safeguarding Children Board. The review was undertaken following the sad death of an 11 year old boy who did not survive a cardiac arrest while on transfer to hospital. He and his family were known to social, primary, secondary and tertiary services due to his complex medical and health needs and there had been known concerns around the relationship between health partners and the child's carers. The findings of the review panel identified learning for all agencies involved in the care of the child. The two key recommendations for GP practices across Lewisham borough are shared here:
• The importance of a co-ordinated approach for children with complex needs. This resonates with other Serious Case Reviews both locally and nationally. In order to support a coordinated approach it is a recommendation of the review that a child with complex health needs has one or two named GP's identified within their registered practice. This will provide continuity of care for the child and carers and help practices to have clear oversight of the care provided.
• In addition it was recognised that a conscious process needs to be in place to consider the health of carers of a child with complex medical and health needs and how this will impact on the outcome for children. While a full medical for such carers is best practice, we recognise this is currently not commissioned. Lewisham CCG will raise this issue with NHS England. In the meantime, we ask that you are mindful of the health of such carers in your contacts with children, in order to have a clear picture of the lived experience of the child. We would be grateful if these two recommendations taken on board and processes put in place to implement them and improve the outcomes for children with complex medical and health needs

Dear Coroner A Harris Re: Master Omarian Brooks Regulation 28 – Action to Prevent Future Deaths I have read carefully your report regarding the tragic and untimely death of Omarian Brooks and have discussed this with senior colleagues within the RCPCH in order to respond to your request. You have asked us to consider how to offer advice on mitigating such tragedies and I would like to offer the following response. COMMUNICATION AND CARE PLANNING
• Children with complex disability should have a named neurodisability paediatrician responsible for regular review, and to provide health information for developing health care plans. This will include plans for management in different settings and done in conjunction with the education health care plans, with plans for management in school, at home, in respite care, and for transport and emergency situations. Plans should be developed with parents and carers, and by those providing the care in different settings, and should be shared with primary care teams.
• RCPCH standards for emergency care1 describe the importance of linking emergency care settings with specialist nurses and community children’s nursing teams to ensure effective planning and follow-up.
• Whilst we do not have all the details or specifics of the case, a breakdown in communication between the parents and health professionals involved in Omarian’s care may have occurred. The College will continue to signpost and develop courses that focus on ensuring awareness of communication issues in relation to children with disability, all of which emphasise the importance of listening to parents and of ensuring patient-centred care. We 1 https://www.rcpch.ac.uk/sites/default/files/2018-06/FTFEC%20Digital%20updated%20final.pdf Charityin England and Wales: 1057744 Registered charity in Scotland SCO38299
- PATRON HRH The Princess Royal

have developed toolkits with children and young people with a hidden condition or illness to help raise awareness of conditions and support services2.
• In 2018, the College brought together the Royal College of General Practitioners, Royal College of Nursing, Royal College of Physicians and Royal College of Psychiatrists to develop Facing the Future: Standards for children with ongoing health needs3 to ensure connectivity between services, with a focus on improving long term care and management so that care is planned and proactive - particularly with improving communication and education for both the child and family, and communication between professionals.
• The standards recommend that service planners, providers and commissioners work together to ensure children and young people experience a high-quality and safe service that empowers children and their families to access timely care for the management of their condition. This includes ensuring a prompt and timely diagnosis with local networks improving communication between professionals so that children and families are supported to manage their conditions.
• The College has a published position on information sharing and maintains that having a unique, consistent identifier for children will allow professionals interacting with children to share information easily and provide better care for their needs.4 SEPSIS: RECOGNITION AND MANAGEMENT
• The College and NHS Improvement developed a framework with clinicians and experts to improve recognising and responding to children at risk of deterioration5. This was in response to research showing that failures to recognise and treat patients whose condition was deteriorating causes significant unintended harm.
• The College has also developed free to access paediatric sepsis podcasts that have been designed as educational resources for health and social care professionals. They explore what sepsis is, the complexities of how to recognise and manage sepsis, what is different about sepsis in children with complex health conditions and much more6.
• The College is also working with NHS England and the Royal College of Nursing to develop a systematic paediatric early warning system, to develop a consistent approach and common language to promptly recognise 2 https://www.rcpch.ac.uk/resources/hidden-health-parent-led-card-toolkit 3 https://www.rcpch.ac.uk/sites/default/files/2018­ 04/facing_the_future_standards_for_children_with_ongoing_health_needs_2018-03.pdf 4 https://www.rcpch.ac.uk/resources/nhs-number-unique-identifier-children-position-statement 5 https://www.rcpch.ac.uk/resources/safe-system-framework-children-risk-deterioration 6 https://www.rcpch.ac.uk/resources/paediatric-sepsis-podcasts Charityin England and Wales: 1057744 Registered charity in Scotland SCO38299
- PATRON HRH The Princess Royal

and respond to the acutely ill or deteriorating infant, child or young person. Thank you for raising this important case and reminding us of the importance of this work.

Dear Mr Harris Regulation 28: Prevention of Future Deaths Report for Master Omarian Brooks Thank you for your Regulation 28 Prevention of Future Deaths Report (PFD) dated 29 May
2020. I would like to take this opportunity at the outset of my letter to offer my deepest condolences to Master Brooks' family. Following the conclusion ofthe above inquest, the London Ambulance Service NHS Trust (LAS) understands from the PFD report that the learned Coroner has recommended that the London Borough of Lewisham, the LAS, Sydenham Green Group Practice and Lewisham & Greenwich NHS Trust work together on the issue of inter-agency working to prevent future similar deaths. The matter of concern for the LAS is the dispute regarding the conveyance to hospital and the Patient Specific Protocol (PSP), which I will address in turn:
1. Managing the Conveyance of Patients The LAS's position on conveying patients to the most appropriate destination is detailed in OP/014 Managing the Conve ance of Patients Policy and Procedure. During the inquest you were advised by Ms Sector Senior Clinical Lead, that this policy was due to be updated but due to t e curren pandemic it has not been possible for the LAS to carry out this update. The LAS endeavours to update this policy by the end of October 2020. Given that this patient was presenting with a potentially critical illness, conveyance to the nearest emergency department was indicated. The acceptable exceptions to conveying the child to another hospital would not apply in an emergency situation save for the nearest unit not being equipped to deal with a paediatric patient. This would not have been the case with Lewisham Hospital which has a paediatric emergency department. The crew had correctly identified that the child was critically unwell and moved to convey them to the nearest emergency department as per policy. Furthermore, during the inquest you were also advised by Ms -that the Policy for Consent to Examination or Treatment (OP/031) will be updated by herself. However, due to the current

pandemic Ms -was re-deployed to frontline clinical duties and therefore it was not possible to carry out this update. However, at the time of writing Ms - is liaising with the relevant persons within the LAS to progress the update of this policy and endeavours to update this policy by the end of October 2020.
2. Patient Specific Protocols (PSP) In 2017 the LAS was operating a PSP process which involved the patients' regular clinician (GP or Hospital Consultant) completing paper forms detailing the specific clinical requirements that may be required for their patient's condition. This form was faxed or emailed to the LAS, in order to provide supplemental information to the crews when attending the patient in an emergency. The PSP lasted for 1 year with the responsibility of renewing and updating it lying exclusively with the clinician who initially completed it. A PSP has never and can never be written by the LAS as this responsibility lies with the patients' regular clinician. A 'flag' in the Emergency Operations Centre {EOC) mapping system was placed so if an emergency call was received by the LAS for that address a little note would come up to say there was a PSP. It was clear to the LAS that this system was not optimal for all of our patients so in collaboration with NHS England (NHSE) and NHS Improvement (NHSI) the LAS transitioned to use the Coordinate My Care (CMC) system for PSPs in 2019. Around February 2018 with the roll-out of iPads, the LAS wrote to acute Trusts in London to inform them that the practice of holding PSPs within our control room was going to be phased out within the next year due to the introduction of the CMC system. All Trusts were asked to review existing PSPs and transfer them to the CMC system. In April 2019 the LAS again wrote to acute Trusts in London to reiterate the introduction of the CMC system and asked all clinicians to review existing paper PSPs in existence and transfer them onto the CMC system by 1st July 2019. The transition process was robust and overseen by NHSE and the Healthy London Partnership. CMG is a system owned and governed by The Royal Marsden Hospital for the sharing of specific clinical and patient information pan London accessible by any and all Hospitals and Clinicians, once they obtain log in credentials. The goal being that important clinical information I could be seen by any organisation with a single log in as opposed to being held in isolation in I! multiple systems at multiple trusts or practices and therefore not visible in a true emergency. Ii Following the support from NHSE and NHSI, CMC is now the current and only system by which 1'il the LAS is able to safely, efficiently and effectively access PSPs. Ambulance clinicians now have immediate access to up to date specific clinical information about that patient, including Fi ll complex issues encountered at the end of someone's life. l An additional functionality that CMC affords patients is the ability to start their own record. This initial record is subsequently clinically validated by the patient's usual clinician in discussion with the patient themselves. This function is called "My CMC". The CMC team, Healthy London partnership, NHSE and NHSI all continue to work with stakeholders to improve and refine the CMC system with the vision that it will become the single point of contact for detailed clinical patient information in an emergency pan London. At the time of writing, the LAS's legal services department has contacted the legal representatives of London Borough of Lewisham, Sydenham Green Group Practice and Lewisham & Greenwich NHS Trust to co-ordinate a meeting. It has been suggested that 2

representatives of each agency meet with t~akeholder Engagement Manager for South East London, Mr and Ms - A mutually convenient date for such meeting is yet to be agreed. I hope this response is helpful in explaining the specific actions undertaken by the LAS.