Selina Samarina
PFD Report
All Responded
Ref: 2024-0299
All 1 response received
· Deadline: 31 Jul 2024
Coroner's Concerns (AI summary)
Despite consolidated rotas, there's an overall insufficiency of doctors in Emergency and Paediatrics Departments, with only 60% staffing, raising concerns about service capacity.
View full coroner's concerns
(1) I was told in evidence that the Trust has now consolidated the staffing rotas for the Emergency Department and Paediatrics Department, so that it is now easier to see any deficit as one deficit across two departments. That does not however, address the situation of how and why a situation in which only 60% of the doctors are available for these important services.
(2) I am concerned about the overall sufficiency of the staffing arrangements.
(2) I am concerned about the overall sufficiency of the staffing arrangements.
Responses
Action Taken
The Trust has improved how paediatric shifts are allocated to the Emergency Department and developed governance and management around staffing the Emergency Department. (AI summary)
The Trust has improved how paediatric shifts are allocated to the Emergency Department and developed governance and management around staffing the Emergency Department. (AI summary)
View full response
Dear Mr Simblet KC
Regulation 28 Report to Prevent Future Deaths- Selina Samarina
I write further to your Regulation 28 Report to Prevent Future Deaths (PFDR) dated 19th June 2024, relating to the Inquest of Miss Selina Samarina.
I have carefully reviewed your report and discussed your concerns with my colleagues in the related specialties. I have set out below our response to the concerns raised.
Matters of Concern
(1) I was told in evidence that the Trust has now consolidated the staffing rotas for the Emergency Department and Paediatrics Department, so that it is now easier to see any deficit as one deficit across two departments. That does not however, address the situation of how and why a situation in which only 60% of the doctors are available for these important services.
(2) I am concerned about the overall sufficiency of the staffing arrangements.
The Trust has now improved how paediatric shifts are allocated to the Emergency Department to ensure that it is adequately staffed. We have developed the governance and management around staffing the Emergency Department so that we can promptly escalate staffing issues before a shift commences, and appropriately manage and mitigate any potential staffing concerns.
Whereas previously, the Paediatric Department had the responsibility of identifying and allocating Paediatric shifts for Paediatric Emergency Department cover to staff, this task is now undertaken by the Emergency Department team themselves. This change ensures that the Emergency Department can identify which shifts are required by grade and experience level according to the demand across the whole department. These shifts are then approved within the care group and the Paediatric team assist in identifying suitable cover where Paediatric skills are specifically needed. 1
The Emergency Department team are of course better placed to review the staffing arrangements as they possess the knowledge of staff competencies within their teams and can ensure that a safe staffing skill mix is met for each shift. This extends to not only the medical teams, but also the wider staff groups including for example allied professions and Advanced Nurse Practitioners.
Our rota-coordinators are completing regular checks throughout each day to maintain safe staffing levels in the Emergency Department, and we hold early multi-disciplinary planning meetings ahead of each weekend to carefully manage unforeseen risks and issues such as sickness. The rota coordinators can request authority to put shifts out to bank or agency if required, and if these cannot be filled, we have a clear escalation route to the senior management teams to devise mitigation plans if required. However, in practice this happens only occasionally as we are forward planning in good time and bank shifts are usually filled.
As a comparison, and for assurance of the improvements we have made since this tragic case, I have attached our audit data collated for the Easter period in 2024, names of the staff members have been redacted. The data shows that very few shifts were unfilled during this period, despite this often being a challenging time to cover shifts, and middle grade and Consultant rotas were well filled. Senior doctor cover was as planned especially on the late shifts going into the evening and overnight.
We will continue to monitor the staffing of the Emergency Department as part of our ongoing audit programme, and we are confident that we are now in a much-improved position. We are grateful for you bringing this issue to our attention and are grateful for the opportunity to learn from these events. We hope that the action we have taken, and will continue to take, has provided assurance that your concerns are being addressed. If you have any further concerns or you would like to discuss this case further, please do not hesitate to contact me.
Regulation 28 Report to Prevent Future Deaths- Selina Samarina
I write further to your Regulation 28 Report to Prevent Future Deaths (PFDR) dated 19th June 2024, relating to the Inquest of Miss Selina Samarina.
I have carefully reviewed your report and discussed your concerns with my colleagues in the related specialties. I have set out below our response to the concerns raised.
Matters of Concern
(1) I was told in evidence that the Trust has now consolidated the staffing rotas for the Emergency Department and Paediatrics Department, so that it is now easier to see any deficit as one deficit across two departments. That does not however, address the situation of how and why a situation in which only 60% of the doctors are available for these important services.
(2) I am concerned about the overall sufficiency of the staffing arrangements.
The Trust has now improved how paediatric shifts are allocated to the Emergency Department to ensure that it is adequately staffed. We have developed the governance and management around staffing the Emergency Department so that we can promptly escalate staffing issues before a shift commences, and appropriately manage and mitigate any potential staffing concerns.
Whereas previously, the Paediatric Department had the responsibility of identifying and allocating Paediatric shifts for Paediatric Emergency Department cover to staff, this task is now undertaken by the Emergency Department team themselves. This change ensures that the Emergency Department can identify which shifts are required by grade and experience level according to the demand across the whole department. These shifts are then approved within the care group and the Paediatric team assist in identifying suitable cover where Paediatric skills are specifically needed. 1
The Emergency Department team are of course better placed to review the staffing arrangements as they possess the knowledge of staff competencies within their teams and can ensure that a safe staffing skill mix is met for each shift. This extends to not only the medical teams, but also the wider staff groups including for example allied professions and Advanced Nurse Practitioners.
Our rota-coordinators are completing regular checks throughout each day to maintain safe staffing levels in the Emergency Department, and we hold early multi-disciplinary planning meetings ahead of each weekend to carefully manage unforeseen risks and issues such as sickness. The rota coordinators can request authority to put shifts out to bank or agency if required, and if these cannot be filled, we have a clear escalation route to the senior management teams to devise mitigation plans if required. However, in practice this happens only occasionally as we are forward planning in good time and bank shifts are usually filled.
As a comparison, and for assurance of the improvements we have made since this tragic case, I have attached our audit data collated for the Easter period in 2024, names of the staff members have been redacted. The data shows that very few shifts were unfilled during this period, despite this often being a challenging time to cover shifts, and middle grade and Consultant rotas were well filled. Senior doctor cover was as planned especially on the late shifts going into the evening and overnight.
We will continue to monitor the staffing of the Emergency Department as part of our ongoing audit programme, and we are confident that we are now in a much-improved position. We are grateful for you bringing this issue to our attention and are grateful for the opportunity to learn from these events. We hope that the action we have taken, and will continue to take, has provided assurance that your concerns are being addressed. If you have any further concerns or you would like to discuss this case further, please do not hesitate to contact me.
Sent To
- South Essex NHS Partnership
Response Status
Linked responses
1 of 1
56-Day Deadline
31 Jul 2024
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 11th April 2023, I commenced an investigation into the death of Selina Samarina, aged 2. The investigation concluded at the end of the inquest on 28th May 2024. The conclusion of the inquest was that the deceased died of natural causes, the medical cause of death being that she had died from sepsis and pneumonia, with contributory factors of Down’s Syndrome and Upper Respiratory Tract infection. She died in Broomfield Hospital
Circumstances of the Death
Selina had been brought into hospital by her parents with symptoms of fever, a rash and irritability. She was made an urgent referral and the sepsis protocol/ procedure was triggered. That should ordinarily lead to an examination by a senior doctor within an hour. In this case, a very junior doctor was sent over, in part because there was huge demand on the ward services and the available doctors of seniority were otherwise engaged with other patients. Selina’s diagnosis was thus arrived at by a relatively junior doctor, and other possible diagnoses such as sepsis or pneumonia were not addressed.There was no differential diagnosis. It was not until two and a half hours later that a doctor of appropriate seniority was available to assess Selina, by which time, as was consistent with the directions from the junior doctor, Selina had gone home with her parents. Evidence was given by the consultant that on that particular day, a Bank Holiday (Good Friday), there would normally be 12 doctors across the Emergency Department and Paediatrics Department, but on that day, there were only 7. This increased workload and the demand for services (which was at a normal level) had played a part in the consultant not being available to review Selina’s condition within the timescale mandated by the sepsis protocol,
Copies Sent To
Since the deceased was under 18, it may also be necessary to inform the LOCAL SAFEGUARDING BOARD (where the deceased was under 18)]. Health Service England
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.