Dear Ms Combes,

James Edward Philliskirk (deceased) Regulation 28

Please find enclosed Sheffield Children’s NHS Foundation Trust’s formal response to your Regulation 28 Report to Prevent Future Deaths dated 10 May 2023. Under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 you requested the Trust to consider your matters for concern and take action to prevent future deaths.

As Chief Executive of the Trust, I met with on 12th June 2023. I took this opportunity to say how very sorry I am to James and everyone who loved him, that Sheffield Children’s Hospital contributed to James’s death by neglect. I am sorry that we misdiagnosed him and that he wasn’t provided the right treatment whilst in our care.

I feel regretful that we did not meet sooner and whilst it felt important to apologise in person, I also regret that we were not in touch with the family straight after the inquest to offer our apologies. This is something I have ensured we change straight away.

The outcome of the inquest and matters for concern for preventing future deaths, our serious incident actions and wider review of areas for improvement, all ensure we will learn and take action. However, hearing James’s story directly from his parents, and their lived experience over the last year, brought into stark focus the areas we must learn from at Sheffield Children’s Hospital. I took immediate personal action to ensure I was fully appraised and assured of the actions we had in place and continued to take.

We also accepted generous offer to speak to our Trust Board and she joined us on Tuesday 27th June. The impact of our whole Board of Directors hearing James’s story directly from was palpable. It was a poignant moment in our Trust history that will be remembered by us all and will inform how we seek assurance in the future. I have arranged to provide a full update to in July and this will be followed up with a meeting on 13th July 2023.

I trust that this letter and the enclosed Trust’s Regulation 28 Response provides adequate assurance on the matters of concern.

Western Bank Sheffield S10 2TH

Chief Executive

Chair

Please do not hesitate to contact myself if you require anything further.

Dear Ms Combes,

James Edward Philliskirk (deceased) Regulation 28

I write in response to your Regulation 28 Report to Prevent Future Deaths dated 10 May 2023. Under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 you requested the Trust to consider your matters for concern and take action to prevent future deaths.

The Matters of Concern and the Trust’s responses are as follows:

1. Junior staff not knowing when to escalate concerns.

In order to address this concern, improvements to the induction training for junior doctors have been made. These improvements have included providing information on when junior staff should escalate concerns to senior staff. The guidelines relating to reattenders, fever, chicken pox and sepsis are brought to the attention of the junior doctors so that they are clear on when it would be appropriate to escalate. In addition, junior doctors receive regular WhatsApp messages and emails alerting them to any prevalent illness and the relevant training and information they need to access at that time.

Work is also ongoing to increase senior leadership within the Emergency Department (ED) at the Trust by implementing a new Specialty Doctor rota and increasing the consultant hours within ED. A Trust job advertisement closes today for 2 Speciality Doctors and the Medicine Care group have applied for funding to add an extra Consultant shift every weekend, with locum shifts to be offered by October in the event that funding has not been secured.

With an increased presence of senior decision makers, there will be greater supervision of junior doctors, more senior staff to review re-attenders alongside sicker children and an increased capacity for training and audit.

In addition, the Trust’s IT department is working on adding a reattender flag onto the electronic medical records system, which would alert the senior clinicians to the fact that a reattender was in the department. It is anticipated that this will be in place by the end of July 2023.

Western Bank Sheffield S10 2TH

Chief Executive

Chair

2. Unclear guidance in the handbook relating to chicken pox and reinfection and the need for aggressive antibiotic treatment if reinfection occurs soon after the initial infection.

As provided in evidence during this inquest, the guideline relating to chicken pox was amended in response to immediate learning and a copy of this was sent to you on 2 May
2023. Subsequently more work is being undertaken to develop the guidelines further with the Emergency Department clinicians, Infectious disease specialists and the Paediatricians. This work will be completed by the end of September 2023.

3. Confirmation bias affecting clinical reviews.

The induction training for junior doctors now includes a module called ‘Keeping Safe in ED’. In August 2022 this was added to the induction to discuss human factor principles (including confirmation bias) and the importance of listening to parents.

In addition, throughout the Trust, work is being done to raise awareness of human factors, their role in decision making and how errors can occur. Funding has been acquired to make educational videos highlighting this vitally important area. They will be used to support the education of all staff groups now and future cohorts across the Trust as well as in the ED.

4. Lack of proper assessment of existing skin lesions in chicken pox even where identified by parents.

The amended Chicken Pox Guideline is now clearer on how secondary bacterial infections can present.

The new Induction module “Keeping Safe in ED” covers key learning from this case about chicken pox as well as the importance of listening to parents.

Human factor training planned as part of the educational video will cover areas like heuristic thinking and confirmation bias which were factors in this case. Raising awareness to staff of these factors in decision making will help future decision making in the highly pressurised environment of ED.

Prior to induction, ED junior doctors receive a pack which includes a chapter on paediatric rashes including chicken pox. Four hours of training time is given to ED junior doctors each week and they are encouraged to cover this pre-induction pack in their first few weeks if not covered prior to starting, to ensure they have appropriate knowledge of rashes and risks of secondary complications. This will ensure that they assess rashes effectively in the ED.

Work is in progress to increase ED senior staffing to allow enhanced supervision of juniors assessing patients including those with rashes and support further education.

5. Lack of knowledge of the risk of secondary complications from recent chicken pox infection in the emergency department.

The risk of secondary complications from recent chicken pox infection is included in the Trust Guideline relating to chicken pox. As provided in evidence during this inquest and also in response to point 2 above, the guideline relating to chicken pox has been amended and a copy of this was sent to you on 2 May 2023.

The amended guideline is clearer on how complications present clinically. Further work is being undertaken to develop the guidelines with the Emergency Department clinicians, Infectious disease specialists and the Paediatricians and this work will be completed by the end of September 2023.

Chief Executive

Chair

A new Chicken Pox Patient Information Leaflet has been drafted and sent to be processed on the patient resource library.

Knowledge of important complications in any febrile child including chicken pox is covered in ED Induction and specifically in the new “Keeping Safe in ED” session.

Increasing the ED Senior workforce is a top priority for the department and Trust to enable enhanced teaching, training and supervision both clinically and non-clinically. Recruitment is in progress, with the aim to have the first phase of increased staffing by October 2023.

6. Insufficient weight on GP referral when not through the identified route of referral (i.e. presentation straight to A&E which amounts to 25% of referrals).

As confirmed in evidence at the inquest, a reminder has been sent via the Integrated Care Board communications team to primary care, reminding them of the current referral system, so that the correct referral pathway is used, including a reminder to provide a copy of a new leaflet to parents explaining the system in place and the need to attend AAU (The Acute Assessment Unit).

As a safety net, any patient arriving with a letter from the GP but who has not been formally referred through the correct pathway, will be seen by the appropriate team as they would, had the correct referral pathway been followed.

If a patient has been seen in primary care and not formally referred and it is unclear which team at the Trust should see the child, an ED Consultant will review the letter to ensure they are seen by the appropriate team.

Our clinical management team will be working with our primary care colleagues towards a more permanent solution for the referral aspect of the patient pathway. At this time, we are unable to confirm whether this will require a digital solution such as an electronic referral system but have oversight from our digital colleagues to ensure that if such a solution is required it can be practically implemented.

I trust that this provides adequate assurance on the matters of concern. Please do not hesitate to contact myself if you require anything further.