During the investigation, Healthcare a) I heard expert evidence that GPs and general hospital doctors would benefit from national guidance to ensure that greater consistency is achieved when referring children for tonsillectomy and similar treatment. In addition, both GP and hospital doctors gave evidence that raised a concern regarding:
i. whether additional guidance may be appropriate to help doctors decide which cases need an urgent referral to hospital or tertiary care; and
ii. a system of red flags – for example including choking in the ENT UK Commissioning Guide for Tonsillectomy (2016). Experts and witnesses confirmed that choking is not mentioned in the current Guide. b) I also heard evidence from experts that when a child chokes as James did in May 2017, the risk of a life-threatening event is high. I was concerned to hear that A&E paediatricians could either refer directly to ENT specialists or arrange a follow-up visit to assess the likelihood of a repeat choking episode but in this case the child’s mother was referred back to the GP. c) I heard evidence that at some points in James’s medical care there were delays in being reassessed especially following the sleep study. The delay in being reassessed and referred to tertiary care was contributed to by medical staff being on leave. Doctors will inevitably have leave yet I am still concerned that systems in place at that time were not sufficiently robust to ensure suitable cover was in place to progress urgent cases. d) I also heard evidence to suggest that locally devised priorities agreed in specialist or tertiary centres (in this case the Royal Sussex County Hospital, Brighton) had not been communicated to local hospitals and shared so that doctors making a referral can consider the best place to refer a case taking into consideration relative waiting times. e) One expert medical witness gave evidence that it may help other parents in a similar position to the parents in this case to be given a leaflet by Emergency and ENT departments setting out advice on choking hazards including food and/or how best to manage a choking episode including what information to give during a 999 call. f) At several points during the inquest, questions were asked of medical witnesses about how best practice is shared between local NHS Trusts and GP surgeries. I am concerned that systems to review how information is shared locally may need to be reconsidered. Bourne Leisure Ltd (including Butlins) a) From speaking to a number of witnesses in this case, I was deeply concerned that there was no national system for managing Health & Safety issues across company sites. Staff agreed it would help to share information and learning on a reciprocal basis across all sites. b) After hearing extensive evidence, I was deeply concerned about whether there was a sufficiently robust incident investigation and reporting system in place so that lessons could be learned then shared with staff. c) I am concerned that the Health & Safety Executive’s strong recommendation in the First Aid Regulations to consider the first aid of visitors and what will be offered in terms of provision across each site was not sufficiently reflected in company practices. d) I was concerned to hear evidence that many months after this tragic incident during Tots Week, installation of an external phone line and sufficient AEDs in key areas such as restaurants and swimming pool areas had not been completed. e) Witnesses confirmed that there was no written standard operating procedure setting out how staff can get first aid help quickly as well as when and how to make a 999-emergency call especially if a trained first aider is not immediately available.