Dear Mr Merchant

Re: RCPCH Response to the Inquest Touching the Death of Yahya Muhammad Hayat A Regulation 28 Report – Action to Prevent Future Deaths

Thank you for sharing your letter of concern with us regarding the tragic and untimely passing of Yahya Muhammad Hayat. I was very sorry to hear of Yahya’s death. I have discussed your concerns with the leaders of our Education and Training Department. We have read your report carefully and note the following RCPCH activity in relation to the two matters of concern.

1. The fact training [specifically compulsory direct observed training to be assessed as competent to perform neonatal intubation] is no longer compulsory, increases the reliance on consultants (who in some clinical settings may be non-resident on call depending on when delivery takes place)

The Progress+ curriculum for paediatrics provides placements in neonatology between ST1- 4, providing opportunities to develop knowledge and practical skills. Historically, training in safe airway management and intubation has taken place on neonatal placements and this will carry on during Progress+.

As noted in the report, with the introduction of the new Progress+ curriculum, the requirements for a mandatory successful DOPS (direct observation of procedural skills) for neonatal intubation has been removed, however key capabilities to manage a neonatal airway safely have been broadened and strengthened. This is in line with current evidence that in most cases a neonatal airway can be maintained more safely and reliably with non- invasive techniques, especially in inexperienced hands.

Evidence is clear that repeated intubation attempts are associated with significant trauma. This is more likely if the operator is inexperienced, and crucially non-invasive techniques include not just good bag valve mask ventilation but also use of a supraglottic airway as a safe and more easily taught alternative to invasive endotracheal intubation. The previous mandatory DOPS approach, whereby all Level 1 trainees needed to achieve a single successful DOPS for intubation, provided false reassurance that this group of doctors had

the capability to intubate. This also led to less emphasis on safe non-invasive methods of managing a neonatal airway.

There are other pragmatic reasons behind the curriculum change:
• Fewer neonates get intubated in the current era, therefore training opportunities are limited and should be reserved for those trainees who need confident and reliable intubation capabilities.
• To maintain safe and reliable intubation skills it is necessary to be intubating regularly
• The evidence shows that teaching non-invasive airway skills (including use of supraglottic airway) in simulated environments is more reliable and reproducible than teaching invasive intubation.
• The curriculum should be a resource to train paediatricians for their future roles, therefore expecting all core trainees to acquire beginner skills in intubation when not all of them will need those skills beyond ST4 and when those beginner skills are not safe is not the way forward.

Therefore, from a curricular point of view:
• For core level training, all trainees need to demonstrate airway skills up to the point of intubation, with a focus on good non invasive airway skills (including supraglottic airway)
• At specialty level for general paediatricians, the key capability does include intubation and difficult airway management: Maintains the airway of term and preterm neonates up to and including safe intubation attempt under optimal conditions. Recognises the risks of repeated intubation attempts and if intubation is unsuccessful maintains the airway with adjuncts including supraglottic airway. Can follow a difficult airway pathway with the support of other professionals.

2. Consultant general paediatricians of the future will have a lower level of experience than is currently the case of complex neonatal resuscitation

We acknowledge that, as care of the sickest neonates is concentrated in Level 3 units and the need for intubation is overall reduced, this can result in less opportunity for training and for maintaining skills. This goes well beyond a single procedural capability in the training curriculum for early years trainees, especially in an era of a multiprofessional workforce and increasing numbers of locally-employed doctor staff, especially at more junior levels.

Neonatal care is delivered in operational delivery networks (ODNs) that should have mechanisms for supporting airway and resuscitation skills for all of the units in their network, especially in those where skills may not be used so frequently and need more intentional and regular training.

We have also worked with the British Association of Perinatal Medicine, BAPM, to develop a neonatal airway safety standard that aligns with our curriculum. There is a very clear focus in this document on maintaining skills and ongoing training, and the document contains several resources (log books, multiprofessional simulations etc). to support professionals with the maintenance of skills. We will ensure we are signposting our members to this resource accordingly.

Next steps

The College will be sharing information and suggestions for local improvement from your report with our paediatric members via its patient safety portal. The anonymised information within your report will also be shared for discussion with the RCPCH Clinical Quality in Practice Committee, where further actions may be identified.

Thank you for seeking our views and reminding us of the importance of this work. Our sincere condolences are with Yahya’s family.