Nasar Ahmed
PFD Report
All Responded
Ref: 2023-0134
All 7 responses received
· Deadline: 28 Jun 2023
Coroner's Concerns (AI summary)
A school nurse's inadequate medication review process included using an incorrect allergy action plan, not verifying medication in school, and failing to ensure updated, in-date medication.
View full coroner's concerns
1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist.
2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting.
3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan with the dose of the relevant medication.
These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools.
2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting.
3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan with the dose of the relevant medication.
These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools.
Responses
Action Planned
Bow School is improving medication management systems, ensuring robust monitoring, and supporting staff to provide effective interventions; the school will brief staff on medical policies and procedures (repeated September 2017), place awareness posters throughout the school, annotate menus with allergens (September 2017), raise awareness of medical needs via Anaphylaxis Campaign and PSHE curriculum, and offer first aid training to pupils (Year 9 in July 2017, all pupils next year). (AI summary)
Bow School is improving medication management systems, ensuring robust monitoring, and supporting staff to provide effective interventions; the school will brief staff on medical policies and procedures (repeated September 2017), place awareness posters throughout the school, annotate menus with allergens (September 2017), raise awareness of medical needs via Anaphylaxis Campaign and PSHE curriculum, and offer first aid training to pupils (Year 9 in July 2017, all pupils next year). (AI summary)
View full response
BOW 1 SCHOOL 29th June 2017 Bow School's Response to Prevention of Future Deaths Report On the 12.05.17, following the Inquest into the untimely death of Nasar Ahmed, the Senior Coroner for the Inner North London Coroner Court made a request under the Coroner and Justice Act 2009 and reg.28 Coroners (Investigations) Regulations 2013 for a report from Bow School setting out what actions have been taken to prevent future deaths arising if similar circumstances were to occur again. Alongside this request the Coroner made four further requests from a number of agencies under reg.28. This report addresses the matters of concern raised directly to the school. Please note that, in addition to the actions detailed within this report, the school has actively engaged with other organisations, including Compass Wellbeing and Barts NHS Trust, to support them to review practices and implement actions within their organisations to protect against future deaths in school settings. School staff are also working with the Local Authority's Education Department and Tower Hamlet's Education ['THE'] Partnership to raise awareness with schools across the area of the steps they have taken to minimise risk of similar incidences. The school remain committed to working with parents and pupils to manage medical conditions effectively. They recognise that key to this is improving existing systems and ensuring these are robustly monitored to accurately identify needs and reduce risk. Also pivotal to the improvements is a commitment to supporting staff to provide effective preventative interventions and prompt response to medical emergencies. The Coroner commented within the report that Nasar's mother was present for the medication review conducted by the school nurse on the 03.05.16, but that a member of staff wasn't present. She commented that this was contrary to the school policy. It should be noted that, at time of Nasar's death, the 'Supporting Student with medical needs' policy did not require a member of staff to attend the annual review of an Individual Health Care Plan; rather the requirement was that staff were involved in the original decision to have a plan.1 It should also be noted that this policy complied with the standards expected by national guidance for schools including 'Supporting pupils at school with medical conditions statutory guidance for governing bodies'2, the 'Special Educational Needs and Disability Code of Practice3 and 'Keeping children safe in Education4. Notwithstanding this the school has revised the relevant policy to require that a member of pastoral team responsible for the child, (usually the Year Learning Manager ['YLM'J or the Year Learning Assistant (YLA]) attends the initial meeting and all reviews. It has also been amended so it no longer requires a first aider to contact the Head teacher's personal assistant to call emergency services, but rather requires staff do this immediately and then 1 See page 4 of 2016 policy 2 Published by the Department for Education. available at:
3 https://www.gov.uk/governmenVpublications/send-code-of-practice-O-to-25 4 https://www.gov.uk/governm enVpublications/keeping-children-safe-in-education--2
2 notify the office so that parents can be informed at the earliest opportunity. The revised policies are due to be ratified at the next Governing Body meeting on the 12.07 .17, but staff have already implemented these changes into their practice. The Coroner also raised concerns that the system in place for ensuring that actions arising from individual health plans ('IHP'] and medication reviews were undertaken was not sufficiently robust. Since Nasar's death, the school's Safeguarding Committee has undertaken a thorough review of all IHPs for pupils in the school. This included ensuring that all medicines kept within emergency boxes at the school are as prescribed and in date. The Executive Headteacher, along with Headteacher representatives from across the area, has been invited by the Local authority to meet to discuss the school nursing service as part of a scheduled contract renewal process. This meeting is due to take place later this year, but it is understood that the concerns identified during the Inquest will inform that process. In the interim the school has been working with Compass Wellbeing to clarify the procedure for setting up IHP meetings and medication reviews. The school has additional processes to ensure this procedure is robustly monitored at senior level. The procedure requires that, in all cases an update of the pupil's medical need is required at each review. Principally it remains the responsibility of the child's parents or school nurse to make contact with the child's GP or other medical professionals involved in their care prior to the meeting. Where, at the review meeting, this hasn't been done or there is any uncertainty regarding the pupil's current need the school nurse is required to follow up with direct contact to the pupil's GP and confirm the position to the school administrator by email. The deputy head responsible for safeguarding is also copied into those emails. The procedure also differentiates between medication reviews and IHP meetings/ reviews to ensure that necessary follow up can be scheduled separately. For example, where actions are required as a result of the medication review, a follow up review is scheduled for the following week. Currently both the school nurse and the attending member of staff are required to notify the school administrator if follow up action is required following a review. A reminder is sent by the administrator shortly before the deadline for action to the school nursing service and VLM. The Safeguarding Committee5 has developed a flowchart to outline the responsibilities under the 'Support students with medical needs' policy. The committee has as a standard agenda item 'IHP and medication reviews' so that effectiveness of managing medical needs is considered at each meeting. It is responsible for setting the schedule of meetings for all IHP or medication reviews on a half termly basis. The school administrator is required to liaise with Compass Wellbeing and the YLM to ensure all parties are present at meetings. The Designated Safeguarding Lead ['DSL'] also receives details of IHP .meetings and the decisions made and conducts spot checks on the IHPs and medicines so that compliance with expectations can be maintained. The DSL provides a compliance report each half term to the safeguarding committee. In addition, senior leaders at the school meet with Compass Wellbeing managers on a termly basis to review practice, the implementation of the policy and procedures and to assess the quality of communications between the school nursing service and pastoral teams within the school. Any concerns regarding compliance with those expectations or training needs of staff are also addressed at that meeting. 6 This committee is Chaired by the Deputy Head with safeguarding responsibllltles and attended by the Designated safeguarding lead, the Governor responsible for safeguarding, the SENOCo, Child protection officer, senior first aider, senior colleague responsible for trips and visits, the heads of the upper and lower school and the HR manager who maintains the School's Single Central Register.
3 The Coroner commented that school staff were encouraged to familiarise themselves with pupil's care plans and required to do so for school excursions, but in other circumstances staff may not have been familiar with health needs of all pupils. In response to this the school now have a clear understanding between Compass Wellbeing, parents and pupils that information regarding a child's medical needs will be shared with all staff on the basis that all staff need to have access to, and understanding of, this information. This information has been made more visible for staff as detailed below and policies and processes have been revised to reflect this common understanding, for example, all staff have access to the school's electronic medical needs registers. The amended polices are due to be ratified by the Governing Body on the 12.07.17. In addition, the induction programme for new staff has been amended to include medical needs information in induction packs and training is provided to all new staff on how to access medical needs information on the pupil's SIMs record. All staff are also offered training with Compass Wellbeing on basic first aid. All staff are required to sign to confirm they have read and understood key policies in relation to medical needs and safeguarding. The school has also devised roles and responsibilities charts for key polices, such as:
• Supporting students with medical needs
• Safeguarding and Child Protection
• SEND policy
• Trips and Visits
• Asthma Awareness policy The school extended this support to children in transition, i.e. those moving into the school from Year 6 and in year admissions from other schools. Staff use opportunities such as school visits and induction days to request medical information from parents and the child's current school records. This information is shared with Compass Wellbeing so IHP and medication requirements can be reviewed over the summer holidays and are in place at the start of each school year. This also protects against any gap in IHP or medication reviews. In addition, all lHPs are being scanned and attached to the relevant child's electronic record (the SIMS profile) so that it can ·be viewed quickly by staff. An alert symbol has also been added to relevant pupils' SIM profiles so that it is immediately visible if a child has an IHP. Alerts have also been added to the school's Cashless Catering System to flag students with allergies so that kitchen staff are aware of those children. Catering staff are encouraged to liaise with the relevant pastoral team or Compass Wellbeing to check if unsure and continue to challenge if they feel a pupil's choice may place them at risk. There is also a procedure for catering staff to report concerns where children with allergies regularly seek to purchase food containing allergens. The school's SENDCo will provide briefings to all staff for children. with medical needs each September. Further briefings will be provided to all staff if a child with medical needs starts in year and all new staff receive the briefing as part of their induction if they do not start in September or if a child's needs change following a review. All staff received a briefing on the pupils with medical needs on the 05.06.17 and will receive half-termly reminders. Those reminders will also require they review their 1class context sheets' to ensure medical information for students is up to date. The Safeguarding Committee will undertake spot checks to ensure compliance, the_first of which will be completed by the 04.07.17.
4 Since the Inquest the Deputy Head teacher responsible for safeguarding has reviewed all information held in respect of children with medical needs to ensure that the IHP register, Asthma Register, Allergies Register and Other conditions register is accurate. The registers are now discreetly displayed by type of need, the pupil's name and photograph, symptoms and key actions in each of the staff common areas, the kitchen, learning support areas and internal exclusion room. These are reviewed and updated on a half-termly basis. A fourth issue identified by the Coroner was that not everyone involved in trying to help Nasar was first aid trained. This is correct, however, there is no requirement that all school staff are first aiders. The 'First aid in schools' guidance6 is explicit that it is not a condition of a teacher's employment contract that they provide. first aid. It is a matter for individuals whether they wish to volunteer for those responsibilities, though as an employer a school's Governing Body must ensure that they have sufficient first aiders to provide first aid for school staff. The Health and Safety Executive ( 1HSE'] advises that organisations such as schools consider possible risks to pupils and visitors within their risk assessments and allow for this when determining the number of first aid personnel they may require. It is important to clarify that the school does have an appropriate number of first aiders on site at all times, including on the 10.11.16. Furthermore, whilst it wasn't referenced within the narrative determination, the school's arrangements to safeguard students was subject to review by OFSTED on the
17.11.16 and found to be effective, in particular OFSTED commended the rigour of risk assessments for school trips. Within her narrative determination the Coroner recognised that the learning assistant responded immediately when Nasar said he was unwell and that a first aider was with him within 20 seconds. She reported that the first aider made preliminary checks with Nasar, including asking him if he had pre-existing conditions or had experienced symptoms before and then rang for an ambulance and sought their advice on how to best assist Nasar. The Coroner also noted that a second first aider attended within two minutes and, recognising that he did have a pre-existing condition, requested his IHP (and, by implication, medication). The Coroner rightly recognised within the narrative determination this was 'a very pressured situation'. She queried whether staff may have responded differently if they had received training or, for those who had, whether they may benefit from additional first aid training. It is important to highlight that staff administering first aid are not expected to perform those responsibilities to the standard of care that clinicians trained to perform emergency medical interventions are held to. The guidance simply requires that staff use their 'best endeavours to secure the welfare of the pupil'. It is understood that the Coroner did not intend her comments to be taken as a criticism of the actions of staff on that day. To do so may well have an unintended consequence of deterring otherwise willing volunteers from taking on these vital responsibilities. She recognised staff had responded immediately and sought appropriate advice on administering the EpiPen from the London Ambulance Service operator and paramedic, but were not instructed to do so because the classic signs of anaphylaxis were not obvious. The outcome, despite the staff best endeavours, was tragic in this instance. The school appreciates that publishing this report, alongside those from all agencies asked to respond to the Coroner's concerns, offers a further opportunity to publicise 8 Issued by the Department for Education In 2000, available at
r_schools.pdf
5 .. the potential lifesaving messages around use of EpiPens in such circumstance and we fully endorse this. The school is also grateful for the opportunity this report affords them to provide assurance that staff and pupils have been offered additional first aid training and to report that the whole school community have embraced those opportunities. A further 25 members of staff have volunteered to complete a first aid training course approved by the HSE over the next academic year, many have already completed their training including all staff responsible for supervising internal exclusion room. The safeguarding committee have devised a first aid training plan, which was presented to and approved by the Governing Body's standards committee on the 14.06.17. This ensures that staff supervising areas of small group work, learning assistants and those who lead in higher risk subjects (e.g. PE, technology and science) are prioritised for HSE first aid training. First aid training programmes are added to the calendar at the start of each academic year, with staff identified for each course. This can only be amended on the authority of the Headteacher. In addition, those who have already completed their HSE first aid programme will receive an additional one-day training on asthma, allergies and Epi-Pen. This is in addition to the first aid training at work refresher courses. Those members of staff who have already completed a HSE approved first aid training course will, from September 2017, meet monthly with the school nurse to share information and review latest advice, guidance and practice. The school's half-termly safeguarding bulletins contain an updated list of all first aiders in the school and they have agreed to run regular briefings for staff at the start of each half-term. They will also run briefings for pupils on a rolling programme so that there is increased awareness of who on the staff team have first aid training. On the 05.06.17 a member of the Governing Body who is also a GP provided a briefing to all staff on the policy and procedures for supporting students with medical needs .. He explained how to identify Asthma and Anaphylaxis symptoms which indicate medical needs were escalating or becoming critical and how to respond. This briefing is due to be repeated in September 2017. To raise awareness more widely across the school posters have been placed in all classrooms and throughout the school, including in the dining pavilion. These detail the steps to take where someone is having an asthma attack or allergic reaction. Allergens posters continue to be placed at key sites within the dining pavilion and menus will be annotated with all allergens, not just at Bow School but in all schools supplied by the catering provider. The Executive Headteacher is working closely with the catering provider to ensure that catering staff are trained and aware of their responsibilities within the school's policies and has been assured that the annotated menus will be in place by the beginning of September 2017. On the 11.07 .17 the Deputy Head will meet with of Anaphylaxis Campaign, an awareness raising charity, to discuss how the school could support the work of their campaign and raise awareness more generally. Thereafter, on the 13.07.17 pupils will not be required to follow their usual timetable, instead there will be a themed day of activities and learning opportunities on healthy living. As part of this staff will be raising awareness of what pupils can do to support students with medical needs. The PSHE curriculum will include medical needs awareness lessons. Year 9 pupils will be offered first aid training in July 2017, this will be extended to all pupils in the next academic year.
6 We trust these actions will ensure that o,ur whole school community is equipped to fully support children with medical needs and respond effectively if a medical emergency arises. We remain committed to working with the wider educational networks and services to improve outcomes for those children with medical conditions and, above all, hope that the steps we have taken offer some comfort to Nasar's family and friends.
Interim Associate Head teacher
3 https://www.gov.uk/governmenVpublications/send-code-of-practice-O-to-25 4 https://www.gov.uk/governm enVpublications/keeping-children-safe-in-education--2
2 notify the office so that parents can be informed at the earliest opportunity. The revised policies are due to be ratified at the next Governing Body meeting on the 12.07 .17, but staff have already implemented these changes into their practice. The Coroner also raised concerns that the system in place for ensuring that actions arising from individual health plans ('IHP'] and medication reviews were undertaken was not sufficiently robust. Since Nasar's death, the school's Safeguarding Committee has undertaken a thorough review of all IHPs for pupils in the school. This included ensuring that all medicines kept within emergency boxes at the school are as prescribed and in date. The Executive Headteacher, along with Headteacher representatives from across the area, has been invited by the Local authority to meet to discuss the school nursing service as part of a scheduled contract renewal process. This meeting is due to take place later this year, but it is understood that the concerns identified during the Inquest will inform that process. In the interim the school has been working with Compass Wellbeing to clarify the procedure for setting up IHP meetings and medication reviews. The school has additional processes to ensure this procedure is robustly monitored at senior level. The procedure requires that, in all cases an update of the pupil's medical need is required at each review. Principally it remains the responsibility of the child's parents or school nurse to make contact with the child's GP or other medical professionals involved in their care prior to the meeting. Where, at the review meeting, this hasn't been done or there is any uncertainty regarding the pupil's current need the school nurse is required to follow up with direct contact to the pupil's GP and confirm the position to the school administrator by email. The deputy head responsible for safeguarding is also copied into those emails. The procedure also differentiates between medication reviews and IHP meetings/ reviews to ensure that necessary follow up can be scheduled separately. For example, where actions are required as a result of the medication review, a follow up review is scheduled for the following week. Currently both the school nurse and the attending member of staff are required to notify the school administrator if follow up action is required following a review. A reminder is sent by the administrator shortly before the deadline for action to the school nursing service and VLM. The Safeguarding Committee5 has developed a flowchart to outline the responsibilities under the 'Support students with medical needs' policy. The committee has as a standard agenda item 'IHP and medication reviews' so that effectiveness of managing medical needs is considered at each meeting. It is responsible for setting the schedule of meetings for all IHP or medication reviews on a half termly basis. The school administrator is required to liaise with Compass Wellbeing and the YLM to ensure all parties are present at meetings. The Designated Safeguarding Lead ['DSL'] also receives details of IHP .meetings and the decisions made and conducts spot checks on the IHPs and medicines so that compliance with expectations can be maintained. The DSL provides a compliance report each half term to the safeguarding committee. In addition, senior leaders at the school meet with Compass Wellbeing managers on a termly basis to review practice, the implementation of the policy and procedures and to assess the quality of communications between the school nursing service and pastoral teams within the school. Any concerns regarding compliance with those expectations or training needs of staff are also addressed at that meeting. 6 This committee is Chaired by the Deputy Head with safeguarding responsibllltles and attended by the Designated safeguarding lead, the Governor responsible for safeguarding, the SENOCo, Child protection officer, senior first aider, senior colleague responsible for trips and visits, the heads of the upper and lower school and the HR manager who maintains the School's Single Central Register.
3 The Coroner commented that school staff were encouraged to familiarise themselves with pupil's care plans and required to do so for school excursions, but in other circumstances staff may not have been familiar with health needs of all pupils. In response to this the school now have a clear understanding between Compass Wellbeing, parents and pupils that information regarding a child's medical needs will be shared with all staff on the basis that all staff need to have access to, and understanding of, this information. This information has been made more visible for staff as detailed below and policies and processes have been revised to reflect this common understanding, for example, all staff have access to the school's electronic medical needs registers. The amended polices are due to be ratified by the Governing Body on the 12.07.17. In addition, the induction programme for new staff has been amended to include medical needs information in induction packs and training is provided to all new staff on how to access medical needs information on the pupil's SIMs record. All staff are also offered training with Compass Wellbeing on basic first aid. All staff are required to sign to confirm they have read and understood key policies in relation to medical needs and safeguarding. The school has also devised roles and responsibilities charts for key polices, such as:
• Supporting students with medical needs
• Safeguarding and Child Protection
• SEND policy
• Trips and Visits
• Asthma Awareness policy The school extended this support to children in transition, i.e. those moving into the school from Year 6 and in year admissions from other schools. Staff use opportunities such as school visits and induction days to request medical information from parents and the child's current school records. This information is shared with Compass Wellbeing so IHP and medication requirements can be reviewed over the summer holidays and are in place at the start of each school year. This also protects against any gap in IHP or medication reviews. In addition, all lHPs are being scanned and attached to the relevant child's electronic record (the SIMS profile) so that it can ·be viewed quickly by staff. An alert symbol has also been added to relevant pupils' SIM profiles so that it is immediately visible if a child has an IHP. Alerts have also been added to the school's Cashless Catering System to flag students with allergies so that kitchen staff are aware of those children. Catering staff are encouraged to liaise with the relevant pastoral team or Compass Wellbeing to check if unsure and continue to challenge if they feel a pupil's choice may place them at risk. There is also a procedure for catering staff to report concerns where children with allergies regularly seek to purchase food containing allergens. The school's SENDCo will provide briefings to all staff for children. with medical needs each September. Further briefings will be provided to all staff if a child with medical needs starts in year and all new staff receive the briefing as part of their induction if they do not start in September or if a child's needs change following a review. All staff received a briefing on the pupils with medical needs on the 05.06.17 and will receive half-termly reminders. Those reminders will also require they review their 1class context sheets' to ensure medical information for students is up to date. The Safeguarding Committee will undertake spot checks to ensure compliance, the_first of which will be completed by the 04.07.17.
4 Since the Inquest the Deputy Head teacher responsible for safeguarding has reviewed all information held in respect of children with medical needs to ensure that the IHP register, Asthma Register, Allergies Register and Other conditions register is accurate. The registers are now discreetly displayed by type of need, the pupil's name and photograph, symptoms and key actions in each of the staff common areas, the kitchen, learning support areas and internal exclusion room. These are reviewed and updated on a half-termly basis. A fourth issue identified by the Coroner was that not everyone involved in trying to help Nasar was first aid trained. This is correct, however, there is no requirement that all school staff are first aiders. The 'First aid in schools' guidance6 is explicit that it is not a condition of a teacher's employment contract that they provide. first aid. It is a matter for individuals whether they wish to volunteer for those responsibilities, though as an employer a school's Governing Body must ensure that they have sufficient first aiders to provide first aid for school staff. The Health and Safety Executive ( 1HSE'] advises that organisations such as schools consider possible risks to pupils and visitors within their risk assessments and allow for this when determining the number of first aid personnel they may require. It is important to clarify that the school does have an appropriate number of first aiders on site at all times, including on the 10.11.16. Furthermore, whilst it wasn't referenced within the narrative determination, the school's arrangements to safeguard students was subject to review by OFSTED on the
17.11.16 and found to be effective, in particular OFSTED commended the rigour of risk assessments for school trips. Within her narrative determination the Coroner recognised that the learning assistant responded immediately when Nasar said he was unwell and that a first aider was with him within 20 seconds. She reported that the first aider made preliminary checks with Nasar, including asking him if he had pre-existing conditions or had experienced symptoms before and then rang for an ambulance and sought their advice on how to best assist Nasar. The Coroner also noted that a second first aider attended within two minutes and, recognising that he did have a pre-existing condition, requested his IHP (and, by implication, medication). The Coroner rightly recognised within the narrative determination this was 'a very pressured situation'. She queried whether staff may have responded differently if they had received training or, for those who had, whether they may benefit from additional first aid training. It is important to highlight that staff administering first aid are not expected to perform those responsibilities to the standard of care that clinicians trained to perform emergency medical interventions are held to. The guidance simply requires that staff use their 'best endeavours to secure the welfare of the pupil'. It is understood that the Coroner did not intend her comments to be taken as a criticism of the actions of staff on that day. To do so may well have an unintended consequence of deterring otherwise willing volunteers from taking on these vital responsibilities. She recognised staff had responded immediately and sought appropriate advice on administering the EpiPen from the London Ambulance Service operator and paramedic, but were not instructed to do so because the classic signs of anaphylaxis were not obvious. The outcome, despite the staff best endeavours, was tragic in this instance. The school appreciates that publishing this report, alongside those from all agencies asked to respond to the Coroner's concerns, offers a further opportunity to publicise 8 Issued by the Department for Education In 2000, available at
r_schools.pdf
5 .. the potential lifesaving messages around use of EpiPens in such circumstance and we fully endorse this. The school is also grateful for the opportunity this report affords them to provide assurance that staff and pupils have been offered additional first aid training and to report that the whole school community have embraced those opportunities. A further 25 members of staff have volunteered to complete a first aid training course approved by the HSE over the next academic year, many have already completed their training including all staff responsible for supervising internal exclusion room. The safeguarding committee have devised a first aid training plan, which was presented to and approved by the Governing Body's standards committee on the 14.06.17. This ensures that staff supervising areas of small group work, learning assistants and those who lead in higher risk subjects (e.g. PE, technology and science) are prioritised for HSE first aid training. First aid training programmes are added to the calendar at the start of each academic year, with staff identified for each course. This can only be amended on the authority of the Headteacher. In addition, those who have already completed their HSE first aid programme will receive an additional one-day training on asthma, allergies and Epi-Pen. This is in addition to the first aid training at work refresher courses. Those members of staff who have already completed a HSE approved first aid training course will, from September 2017, meet monthly with the school nurse to share information and review latest advice, guidance and practice. The school's half-termly safeguarding bulletins contain an updated list of all first aiders in the school and they have agreed to run regular briefings for staff at the start of each half-term. They will also run briefings for pupils on a rolling programme so that there is increased awareness of who on the staff team have first aid training. On the 05.06.17 a member of the Governing Body who is also a GP provided a briefing to all staff on the policy and procedures for supporting students with medical needs .. He explained how to identify Asthma and Anaphylaxis symptoms which indicate medical needs were escalating or becoming critical and how to respond. This briefing is due to be repeated in September 2017. To raise awareness more widely across the school posters have been placed in all classrooms and throughout the school, including in the dining pavilion. These detail the steps to take where someone is having an asthma attack or allergic reaction. Allergens posters continue to be placed at key sites within the dining pavilion and menus will be annotated with all allergens, not just at Bow School but in all schools supplied by the catering provider. The Executive Headteacher is working closely with the catering provider to ensure that catering staff are trained and aware of their responsibilities within the school's policies and has been assured that the annotated menus will be in place by the beginning of September 2017. On the 11.07 .17 the Deputy Head will meet with of Anaphylaxis Campaign, an awareness raising charity, to discuss how the school could support the work of their campaign and raise awareness more generally. Thereafter, on the 13.07.17 pupils will not be required to follow their usual timetable, instead there will be a themed day of activities and learning opportunities on healthy living. As part of this staff will be raising awareness of what pupils can do to support students with medical needs. The PSHE curriculum will include medical needs awareness lessons. Year 9 pupils will be offered first aid training in July 2017, this will be extended to all pupils in the next academic year.
6 We trust these actions will ensure that o,ur whole school community is equipped to fully support children with medical needs and respond effectively if a medical emergency arises. We remain committed to working with the wider educational networks and services to improve outcomes for those children with medical conditions and, above all, hope that the steps we have taken offer some comfort to Nasar's family and friends.
Interim Associate Head teacher
Action Planned
The Department of Health will not pursue making generic adrenaline auto-injectors available in public places due to safety concerns raised by the MHRA, but they are amending regulations to allow schools to hold spare auto-injectors without a prescription for emergencies, effective from 1 October 2017, and are developing guidance for school staff on their use. (AI summary)
The Department of Health will not pursue making generic adrenaline auto-injectors available in public places due to safety concerns raised by the MHRA, but they are amending regulations to allow schools to hold spare auto-injectors without a prescription for emergencies, effective from 1 October 2017, and are developing guidance for school staff on their use. (AI summary)
View full response
• Department of Health Office of the Chief Medical Officer Richmond House 79 Whitehall London SW1A 2NS
Ms Hassell HM Senior Coroner, Inner North London St Pancras Coroners Court Carnley Street London N1C 4PP Friday 7th July 2017 Thank you for your letter of 12 May 2017 following the conclusion of the Inquest into the death of Nasar Ahmed. I was very saddened to read of the circumstances surrounding Nasar's death. Please pass my condolences to his family and loved ones. Your Report asked if consideration could be given to making generic adrenaline auto- injectors available in public spaces, in a similar way to that for defibrillators. This followed evidence heard at Inquest that the lifesaving potential of their use could outweigh the risks of harm in similar situations. In giving this consideration, I have taken advice from the Medicine and Healthcare Products Regulatory Agency (MHRA). The MHRA, having deliberated on this, considers such an action could pose substantial risks that outweigh potential for benefit and would need careful evaluation. The MHRA has both clinical and technical concerns. Clinical concerns Adrenaline auto-injectors are indicated solely for the emergency treatment of anaphylaxis and are intended for self-administration by the patient, their carer or another suitably trained person. Patients known to be at risk of anaphylaxis are strongly recommended to carry their prescribed adrenaline auto-injectors with them at all times
recommendation was endorsed by the European Medicines Agency in 2015 following an Article 31 safety referral:
ne auto injectors/human referral 000367.jsp&mid=WC0b01ac05805c516f The provIsIon of communal adrenaline auto-injectors alongside defibrillators in public places would require a member of the public to make a distinction between collapse due to anaphylaxis and collapse for other reasons, including a primary cardiac event such as a myocardial infarction or an arrhythmia. The importance of this distinction is that inappropriate administration of an adrenaline auto-injector to someone suffering from collapse for a primary cardiac reason could increase the likelihood of precipitating a -fatal cardiac rhythm disturbance. Automated defibrillators (particularly newer generation defibrillators) have the diagnostic capability to detect the presence and type of heart rhythm abnormality and whether a shock should be delivered. Modem defibrillators are equipped to deliver shock at the appropriate point in the cardiac cycle. Adrenaline auto-injectors have no ability to detect the cause of the collapse (anaphylaxis or other) and therefore, the decision to administer adrenaline will be dependent on the awareness of the public, an uncertain scenario. The prescriber's information for Epipen, and the Company's website, carry the following caveat; "Use with extreme caution in patients with heart disease .... Cardiac arrhythmias may follow administration of adrenaline." An incorrect choice to use an adrenaline auto- injector in someone suffering from collapse due to a heart attack or other cardiac disturbance could lead to fatal consequences. While it is recognised that during resuscitation for cardiac arrest, particularly for patients in asystole, bolus doses of adrenaline are used, for tachy-arrhythmic events such as ventricular tachycardia, defibrillation is the first choice treatment. Any unintended, inappropriate administration of adrenaline could precipitate a fatal arrhythmia and will therefore require reliance on a considered judgement. Provision of adrenaline alongside defibrillators may introduce an additional decision step about which treatment to administer. Furthermore, administration of adrenaline in cardiac arrest is currently under review, due to uncertainty over benefit-risk. Automated defibrillators have the important safeguard that they only deliver a shock if this is required. The UK resuscitation council guideline on automated defibrillators states: "They are safe and will not allow a shock to be given unless the heart's rhythm requires it." In summary, the MHRA consider that the benefit-risk of defibrillators in public places is clearly favourable (in that the benefits outweigh the risks). Conversely, the benefit-risk of adrenaline auto-injectors in public places is considered to be unfavourable. If adrenaline auto-injectors are made available alongside defibrillators in public places, this risks 2
conflation of their use for "collapse" with potentially fatal consequences. An additional decision step may also deter or delay the appropriate use of a defibrillator. Technical and practical concerns I am advised that there are additional significant technical and practical challenges with the provision of adrenaline auto injectors in public places as outlined below. I. The adrenaline auto-injector devices marketed in the UK each have different instructions for use and are intended to be used by patients or other suitably trained persons to enable correct deployment of the drug. Their use is not intuitive and for an untrained individual seeking to provide emergency assistance, there is a risk that they may either inadvertently self-inject the drug or administer it incorrectly. II. The adrenaline active substance is relatively unstable in solution and particularly sensitive to high temperatures. All the adrenaline auto-injector devices have a short time to expiry of 18 - 20 months from the date of manufacture and need to be protected from extremes of temperature. Above 25°c, the adrenaline auto-injector may well have reduced potency due to increased degradation of drug. In freezing temperatures there is a risk of the drug solidifying making it unable to be delivered. Low temperatures might also cause the device to malfunction (the devices should not be refrigerated). These failures might not be evident to the user. Ill. It would be highly impractical to provide temperature-controlled storage units for adrenaline auto-injector devices held in public places. Even if correctly stored, the device would have to be replaced on its expiry date which would require a responsible person to monitor this. Two or more devices would have to be made available in case needed, introducing further complexity in storing them. IV. The adrenaline auto-injector devices are marketed in three strengths (150, 300 and 500 micrograms) and with differing needle lengths. The prescribing physician will have determined the type of adrenaline auto-injector and strength as appropriate for an individual. In public places, there is a risk of using an inappropriate device potentially delivering an ineffective dose or an excessive dose depending on the circumstances. Permitting adrenaline auto-injectors to be made available in public places would also require a change in the law and therefore a formal review and public consultation process. Based on the complexities involved in the appropriate use of adrenaline auto-injectors, in the clinical situations described above and taking into account the technical and practical 3
issues outlined, the MHRA does not recommended that adrenaline auto-injectors are stored in public places in the same way as defibrillators. On the basis of this advice, I am not currently intending to pursue further the making of generic adrenaline auto-injectors available in public places. However, I am hopeful that work underway to change the law to allow schools to hold spare auto-injectors without a named individual prescription, for use as emergency back- up to treat anaphylaxis in children registered by the school as being in receipt of a medical prescription for an auto-injector, will tackle some of the challenges which staff faced in this sad case, and which were set out in your determination. Our amendments to the Human Medicines Regulations 2012, Parliament permitting, will come into effect on 1 October 2017. Officials are currently working on guidance for school staff in how to obtain and use these auto-injectors appropriately, and the guidance will also provide advice on use of adrenaline more generally. Clinicians from the Anaphylaxis Campaign, as well as lay people, are advising on the content of this guidance, and we are hoping to also bring together training videos on different auto-injectors in a single website. I hope that this guidance, which we will bring to the attention of schools, will greatly reduce the likelihood of a repetition of the tragic events which led to the death of Nasar Ahmed, and so save other lives. Thank you for bringing the circumstances of Nasar Ahmed's death to our attention.
CHIEF MEDICAL OFFICER 4
Ms Hassell HM Senior Coroner, Inner North London St Pancras Coroners Court Carnley Street London N1C 4PP Friday 7th July 2017 Thank you for your letter of 12 May 2017 following the conclusion of the Inquest into the death of Nasar Ahmed. I was very saddened to read of the circumstances surrounding Nasar's death. Please pass my condolences to his family and loved ones. Your Report asked if consideration could be given to making generic adrenaline auto- injectors available in public spaces, in a similar way to that for defibrillators. This followed evidence heard at Inquest that the lifesaving potential of their use could outweigh the risks of harm in similar situations. In giving this consideration, I have taken advice from the Medicine and Healthcare Products Regulatory Agency (MHRA). The MHRA, having deliberated on this, considers such an action could pose substantial risks that outweigh potential for benefit and would need careful evaluation. The MHRA has both clinical and technical concerns. Clinical concerns Adrenaline auto-injectors are indicated solely for the emergency treatment of anaphylaxis and are intended for self-administration by the patient, their carer or another suitably trained person. Patients known to be at risk of anaphylaxis are strongly recommended to carry their prescribed adrenaline auto-injectors with them at all times
recommendation was endorsed by the European Medicines Agency in 2015 following an Article 31 safety referral:
ne auto injectors/human referral 000367.jsp&mid=WC0b01ac05805c516f The provIsIon of communal adrenaline auto-injectors alongside defibrillators in public places would require a member of the public to make a distinction between collapse due to anaphylaxis and collapse for other reasons, including a primary cardiac event such as a myocardial infarction or an arrhythmia. The importance of this distinction is that inappropriate administration of an adrenaline auto-injector to someone suffering from collapse for a primary cardiac reason could increase the likelihood of precipitating a -fatal cardiac rhythm disturbance. Automated defibrillators (particularly newer generation defibrillators) have the diagnostic capability to detect the presence and type of heart rhythm abnormality and whether a shock should be delivered. Modem defibrillators are equipped to deliver shock at the appropriate point in the cardiac cycle. Adrenaline auto-injectors have no ability to detect the cause of the collapse (anaphylaxis or other) and therefore, the decision to administer adrenaline will be dependent on the awareness of the public, an uncertain scenario. The prescriber's information for Epipen, and the Company's website, carry the following caveat; "Use with extreme caution in patients with heart disease .... Cardiac arrhythmias may follow administration of adrenaline." An incorrect choice to use an adrenaline auto- injector in someone suffering from collapse due to a heart attack or other cardiac disturbance could lead to fatal consequences. While it is recognised that during resuscitation for cardiac arrest, particularly for patients in asystole, bolus doses of adrenaline are used, for tachy-arrhythmic events such as ventricular tachycardia, defibrillation is the first choice treatment. Any unintended, inappropriate administration of adrenaline could precipitate a fatal arrhythmia and will therefore require reliance on a considered judgement. Provision of adrenaline alongside defibrillators may introduce an additional decision step about which treatment to administer. Furthermore, administration of adrenaline in cardiac arrest is currently under review, due to uncertainty over benefit-risk. Automated defibrillators have the important safeguard that they only deliver a shock if this is required. The UK resuscitation council guideline on automated defibrillators states: "They are safe and will not allow a shock to be given unless the heart's rhythm requires it." In summary, the MHRA consider that the benefit-risk of defibrillators in public places is clearly favourable (in that the benefits outweigh the risks). Conversely, the benefit-risk of adrenaline auto-injectors in public places is considered to be unfavourable. If adrenaline auto-injectors are made available alongside defibrillators in public places, this risks 2
conflation of their use for "collapse" with potentially fatal consequences. An additional decision step may also deter or delay the appropriate use of a defibrillator. Technical and practical concerns I am advised that there are additional significant technical and practical challenges with the provision of adrenaline auto injectors in public places as outlined below. I. The adrenaline auto-injector devices marketed in the UK each have different instructions for use and are intended to be used by patients or other suitably trained persons to enable correct deployment of the drug. Their use is not intuitive and for an untrained individual seeking to provide emergency assistance, there is a risk that they may either inadvertently self-inject the drug or administer it incorrectly. II. The adrenaline active substance is relatively unstable in solution and particularly sensitive to high temperatures. All the adrenaline auto-injector devices have a short time to expiry of 18 - 20 months from the date of manufacture and need to be protected from extremes of temperature. Above 25°c, the adrenaline auto-injector may well have reduced potency due to increased degradation of drug. In freezing temperatures there is a risk of the drug solidifying making it unable to be delivered. Low temperatures might also cause the device to malfunction (the devices should not be refrigerated). These failures might not be evident to the user. Ill. It would be highly impractical to provide temperature-controlled storage units for adrenaline auto-injector devices held in public places. Even if correctly stored, the device would have to be replaced on its expiry date which would require a responsible person to monitor this. Two or more devices would have to be made available in case needed, introducing further complexity in storing them. IV. The adrenaline auto-injector devices are marketed in three strengths (150, 300 and 500 micrograms) and with differing needle lengths. The prescribing physician will have determined the type of adrenaline auto-injector and strength as appropriate for an individual. In public places, there is a risk of using an inappropriate device potentially delivering an ineffective dose or an excessive dose depending on the circumstances. Permitting adrenaline auto-injectors to be made available in public places would also require a change in the law and therefore a formal review and public consultation process. Based on the complexities involved in the appropriate use of adrenaline auto-injectors, in the clinical situations described above and taking into account the technical and practical 3
issues outlined, the MHRA does not recommended that adrenaline auto-injectors are stored in public places in the same way as defibrillators. On the basis of this advice, I am not currently intending to pursue further the making of generic adrenaline auto-injectors available in public places. However, I am hopeful that work underway to change the law to allow schools to hold spare auto-injectors without a named individual prescription, for use as emergency back- up to treat anaphylaxis in children registered by the school as being in receipt of a medical prescription for an auto-injector, will tackle some of the challenges which staff faced in this sad case, and which were set out in your determination. Our amendments to the Human Medicines Regulations 2012, Parliament permitting, will come into effect on 1 October 2017. Officials are currently working on guidance for school staff in how to obtain and use these auto-injectors appropriately, and the guidance will also provide advice on use of adrenaline more generally. Clinicians from the Anaphylaxis Campaign, as well as lay people, are advising on the content of this guidance, and we are hoping to also bring together training videos on different auto-injectors in a single website. I hope that this guidance, which we will bring to the attention of schools, will greatly reduce the likelihood of a repetition of the tragic events which led to the death of Nasar Ahmed, and so save other lives. Thank you for bringing the circumstances of Nasar Ahmed's death to our attention.
CHIEF MEDICAL OFFICER 4
Action Taken
Compass Wellbeing has undertaken an internal investigation, reinforced accurate record keeping, provided medico-legal training on documentation, reviewed and reran training on their Competency Framework, and is implementing an electronic diary system with reminders for follow-up actions. (AI summary)
Compass Wellbeing has undertaken an internal investigation, reinforced accurate record keeping, provided medico-legal training on documentation, reviewed and reran training on their Competency Framework, and is implementing an electronic diary system with reminders for follow-up actions. (AI summary)
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Dear Madam Coroner, Inquest into the death of Nasar Ahmed - Response to Regulation 28 Prevention of Future Deaths Report This is a response on behalf of Compass Wellbeing ('CWB') to your Regulation 28 Prevention of Future Deaths Report issued following the inquest into the tragic death of Nasar Ahmed. CWB have carefully considered each of the matters of concern raised by you and this response addresses each concern in turn setting out the action taken or proposed to be taken, along with a t imetable for the actions. The purpose of this reply is to set out and demonstrate the actions taken by CWB to ensure that similar deaths do not occur in the future. Following the death of Nasar Ahmed and prior to the inquest commencing in May 2017, CWB undertook an internal investigation into the actions of the staff member directly involved, established core facts and sought to learn lessons from our failures and those of the School Health Service to ensure as best we can that those are not repeated. You may recall that one of our senior members of staff gave evidence to you and the family in May about the steps that were being taken and we take this opportunity to answer your 4 questions and also update vou on the further action the organisation has taken. Steels Lane Health Centre, 384-398 Commercial Road, El OLR Registered in England: 08451249
l' compass wellbeing
1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar's medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist It is established practice that at each child's review meeting, all of the child's medication must be physically present and visually checked by the school nurse. The review must then be recorded in the Child's Health Record and any action points followed up accordingly. It is evident from an investigation carried out by CWB and the evidence given at the inquest into the death of Nasar Ahmed that, on this occasion, our (Nurse) staff member did not carry out a visual inspection of the medication at Nasar's review meeting in May 2016. That is a matter of very deep regret. All of CWB's school nurses receive 'Health Care Plan' t raining as provided by CWB which specifically covers the requirements for reviewing medication and how and when this must be undertaken. The Nurse in this case attended that training in June 2015 and we have attempted to understand whether the failure was an individual one or is wider. We have established that the Nurse had previously undertaken two periods of study successfully completing a practice portfolio demonstrating a knowledge and understanding of reviewing medication during a Health Care Plan meeting. We therefore believe that the Nurse was fully aware of the requirement for medication to be physically present and visually inspected at a review meeting and he should have done so in May 2016 when Nasar Ahmed's medication was reviewed. StepsTaken We have reminded all of our staff that there are no circumstances when a school nurse would not be expected to have the medication in front of them when conducting a review. Our staff have been reminded that we would consider a similar breach to be an act of gross misconduct and would also result in a professional conduct referral. To assist with ensuring that medication is visually inspected by school nurses across the service at review meetings, a checklist has also been introduced for use during Individual Health Care Plan ("IHCP") review meetings. This new measure is designed to ensure that all areas of the review process have been covered during the meeting. This new checklist will act as guidance and prompt to all school nurses and, once completed, will be scanned onto the Child's Health Record. A copy of the 'School annual review asthma/wheeze checklist' is enclosed. The completion of this checklist will form part of the bi-annual IHCP audit, further details of which are provided later in this response. Steels Lane Health Centre, 384-398 Commercial Road, El DLR Registered in England: 08451249
l' compass wellbeing As part of their investigations, CWB have undertaken a wider review of the School Health Service, records kept and IHCPs, all of which are key areas in working to ensure that IHCP and medication reviews are conducted correctly and in a t imely manner. In December 2016, CWB carried out a sample audit of IHCPs to review a cross-section of IHCPs and identify any areas that required improvement across the service. The findings showed that the IHCPs were of a good standard overall. During this review, there were examples of high standards of documented care however, it was noted that there was a lack of consistency across practitioners in terms of recording and articulating details of care plan meetings. As a result of this sample audit, it was identified that there was a need for a more robust approach ensuring that all children requiring an IHCP have one that is in date and fully and consistently detailing the support required; including a particular focus on identifying what action is to be taken in the event of an emergency. An IHCP improvement plan was subsequently implemented to identify, review and monitor all IHCPs across the service using a centralised database. This will support the identification of IHCPs requiring review which will be automatically flagged to the senior management team by an identified data manager. The database has been designed with a flagging system in it. The system counts down in days when an IHCP is due to be renewed and turns the date yellow 60 days prior to the expiry date and red once the date has arrived. The database will be managed by a data team on a daily basis and details of IHCP due (within 60 days) sent via email to the individual nurse responsible for the school and their line manager. This will be overseen by the clinical lead for the service and monitored as part of the performance data for the service. A full Quality Standards Audit was commenced in June 2017 for IHCPs and is due to be completed in August 2017. This audit will review all IHCPs across the whole service. Once this audit has been completed, the annual audit schedule will be extended to include IHCP audits on a bi-annual basis. We will put in place a robust action plan to deal with any deficiencies identified. CWB has also fully reviewed and identified the training received by school nurses and what they are required to receive in order to complete IHCPs in line with CWB's Competency Framework. The Competency Framework is a learning and development resource for nurses and this is completed upon their induction to the service. Re-training has been delivered in line with this Competency Framework. IHCP training has also been undertaken by all staff on 22 June 2017 in order to re-emphasise the role of a qualified nurse with reference to the guidance and the support of administering medication by non- Steels Lane Health Centre, 384-398 Commercial Road, El OLR Registered in England: 08451249
l' compass wellbeing registered (NMC) individuals. As part of the re-training exercise staff were told of the tragic events of this case. In addition to the above training, the bi-annual training received by the school nursing service was delivered in June 2017. During bi-annual training, the service is suspended and training takes place across all staff groups. The training has been tailored to support the key learning points from the tragic death of Nasar Ahmed and the requirements and expectations of a school nurse. It covered a range of key areas including how to improve record keeping and the importance of this, the increased function of school nurse administrators in communication and following up actions with key staff in school and the parents, the use of electronic diary systems and diary management. A copy of the training schedule undertaken in June 2017 is attached. Specific IHCP training will continue to take place on a bi-annual basis. The next scheduled training is for September 2017. We believe that there is now in place a rigorous and proactive approach to auditing, reviewing and monitoring of IHCPs and we are determined to re-enforce the correct medication review process is followed by all of our staff.
2. Although Nasar's mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting CWB recognises and understands the importance of the collaborative working arrangements involved in preparing IHCPs and the ongoing support, communication and processes for children in schools with medical conditions. The Supporting Medical Needs Policy clearly sets out that a number of organisations have roles and responsibilities and that school staff, school nurses and parents must work in partnership to ensure that the needs of pupils with medical conditions are met effectively. Steps Taken Following Nasar's sad death CWB have prepared a Partnership Agreement between CWB and schools across the Borough of Tower Hamlets. This agreement sets out arrangements for support and training for education staff, as well as detailing the expectations across the organisational boundaries. Page 7 of the Agreement (copy enclosed) outlines the roles and responsibilities of the School Health Service and the school. It specifically requires that a member of staff will be identified who will liaise with the School Health Service. The identified school staff member is the person responsible for that child and who has Steels Lane Health Centre, 384-398 Commercial Road, El DLR Registered in England: 08451249
compass wellbeing the appropriate levels of authority to agree possible actions generated from an IHCP and who is able to disseminate information regarding the child's care across the school, including what to do in an emergency. The staff member will work to ensure support and consistency is provided by the school and School Health Service, particularly in relation to the creation of IHCPs and attendance at review meetings. CWB is currently working with the London Borough of Tower Hamlets Public Health and Education departments, as well as Tower Hamlets head teachers representatives, to finalise and roll out the agreements across all schools. Alongside this, joint letters have been sent to all school head teachers within the Borough of Tower Hamlets detailing how schools can become "asthma friendly". This also out lines the expectations and requirements of the school and the School Health Service. This has been prepared and sent in partnership with the specialist teams led by (from whom you heard evidence at the inquest). Furthermore, as part of this partnership, CWB with the assistance of the respiratory clinical nurse specialist, has revised an asthma plan template for children and a process for sharing individual asthma plans with the school nursing service and schools has been commenced. A child's individual asthma plan created by the GP/practice nurse or the specialist team will now be sent directly through to the School Health Service via secure generic email accounts. These email accounts are monitored on a daily basis. The plan will be attached to the child's health record and an email alert sent to the relevant school nurse. Training has been given to our staff team. In addition, school nurses are being supported to actively encourage appropriate members of education staff in the schools to be present during IHCP meetings. All school nurses are aware of the draft Partnership Agreement (see above) which states that there is a requirement for a school staff member to be present at these meetings. With the support of senior managers, school nurses will work to encourage the presence of school staff in IHCP meetings. CWB has also initiated a Project Plan for an incident reporting system called the 'Radar Incident Reporting System'. This system is used to record incidents and risks within the organisation and also highlights where communication difficulties occur, including where IHCP meetings need to be postponed due to non-attendance of education staff. The Radar Healthcare risk register will enable CWB to fully record and manage the major risks to the organisation and t he objectives that they compromise. Risks are prioritised and can be linked to existing incidents and complaints that have been recorded. The system allows regional and corporate risk registers to be managed, with actions, alerts and reviews being tracked to ensure effective risk management. Steels Lane Health Centre, 384-398 Commercial Road, El OLR Registered in England: 08451249
l' compass wellbeing The automated workflow and alert system for each event type ensures that there is a consistent approach to reporting, recording and managing events through the use of electronic event recording forms. Once completed, the event forms generate workflows including identifying reporting lines and governance arrangements and incorporating configured templates to help in performing effective investigations, root cause analysis and trend reporting. The project is being implemented in a number of phases which are set out at page 3 of the attached document. Phase 2 and the training on the use of the Radar system is to be undertaken in August 2017 and it is expected that once Phases 3 and 4 are completed in early September 2017, the system will be fully rolled out to all staff for use. These steps have been taken to ensure that all those involved in the effective care and support of children in schools with medical conditions work effectively and collaboratively and that there is an identified member of staff within each school to play a pro-active part in the preparation and updating of IHCPs and to attend review meetings.
3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar's medication box contained an EpiPen without any description of when or how to use it In evidence to you the Nurse accepted that he used the incorrect care plan. CWB's investigation has concluded that the Nurse had not reviewed the previous IHCP from October 2014 marked "Allergy Action Plan (Severe with Asthma)" or the updated April 2015 IHCP, again marked "Allergy Action Plan (Severe with Asthma)". Both of these previous plans were readily available to the Nurse as they had been uploaded to the EMIS (the electronic health record system} to which he had access. Paper records were also made available to him. When a school nurse is preparing to review an IHCP, it is established practice that they should go onto the EMIS and review the previous IHCP. This did not happen on this occasion. It has further been accepted by the Nurse that even if he did not have access to or see the previous plans, he should have completed the "Allergy Action Plan {Severe with Asthma)" for Nasar Ahmed based on the information he had available to him at the time. As part of CWB's investigation, each of the IHCPs prepared by this Nurse at Bow School were reviewed. CWB's investigation found that other IHCPs prepared by the Nurse had errors in them and were required to be re-written. That process has now been completed. Steels Lane Health Centre, 384-398 Commercial Road, El OLR Registered in England: 08451249
l' compass wellbeing Steps Taken The Coroner is referred to the steps set out in response to the first concern raised and the processes that have been implemented across the service to provide assurances in relation to the auditing, quality and consistency of IHCPs prepared and completed by school nurses.
4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan wit h the dose of the relevant medication The Supporting Medical Needs Policy indicates that the responsibility of checking that in-date medication is provided is a shared one between the school itself and the school nurse. It is fully expected that the school nurse and the school would have a conversation to discuss follow-up actions arising from a meeting and appropriately diarise to check that the correct medication has been received and, if not received, to chase this up in a timely manner. As a qualified health professional, the school nurse is able and expected to understand whether a prescription is appropriate and whether the correct medication has been received. Any outstanding actions must be followed up and completed as a matter of course and in accordance with their professional duties. As referred to above, CWB has carried out an investigation into the actions of the Nurse, including his failure to diarise to ensure that the current medication was provided and in the box. As was evident from the Inquest, the investigation findings are that the Nurses' diary made no mention or record of any follow- up action relating to checking the medication. There is no evidence to show that he checked the medication had been received and was in Nasar Ahmed's box and that is a matter of very deep regret. Steps Taken CWB have implemented additional measures to ensure that the checking and updating of actions from IHCP meetings are routinely followed up by all school nurses and to prevent this event from happening again. All clinical staff have received guidance on how to manage an electronic diary in order to assist staff in diarising appointment, reminders and sharing calendar appointments. All clinical staff have access to mobile working devices, tor example laptops, and the service is moving to a fully electronic diarising system in order to support sharing of appointment calendars and the effective use of an electronic diary and reminder system. Specific training on electronic diarising and the use of this took place on 21 June Steels Lane Health Cent re, 384-398 Commercial Road, El OLR Registered in England: 08451249
ii compass wellbeing 2017 and we believe that the system is fully understood by our staff team. The system will be fully rolled out in the new academic year (September 2017). Furthermore, the bi-annual training referred to earlier above will also cover the use of electronic diary systems and diary management and act as a reminder of our expectations. Having an electronic diary system in place operated by trained staff will enable appointments to be clearly made and set out within the calendar and reminders and electronic prompts to be set. This will assist in ensuring that actions are followed up on a prompt and routine basis. We have told our staff that they should not be afraid of letting us know if they are struggling to 'get to grips' with the electronic system of working. CWB have re-enforced to all staff the requirement and expectation across the service to ensure that accurate and contemporaneous records are kept, including recording and documenting action points and dates for follow up, as well as documenting who is responsible for each action point. This has been re- enforced through medico-legal training which was arranged for all staff in order to address the implications of poor documentation keeping and the effect this has on the delivery of healthcare. This training took place on 19 June 2017. The requirement and importance of record keeping is also set out within CWB's Competency Framework which states that there is a need to "ensure all records are written contemporaneously and in accordance with the NMC record keeping standard and local record keeping and documentation standards and guidelines including local electronic documentation, storage and deletion policies". As referred to previously within this response, this is a framework reviewed and completed by school nurses upon their induction to CWB. Whilst we wish to avoid repetition we confirm that training in relation to this framework and the relevant competencies has been re-run. We hope that this response provides clear and substantive evidence of the actions taken by CWB to prevent future deaths. However, should you require any further information or clarification, please do not hesitate to contact us.
l' compass wellbeing
1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar's medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist It is established practice that at each child's review meeting, all of the child's medication must be physically present and visually checked by the school nurse. The review must then be recorded in the Child's Health Record and any action points followed up accordingly. It is evident from an investigation carried out by CWB and the evidence given at the inquest into the death of Nasar Ahmed that, on this occasion, our (Nurse) staff member did not carry out a visual inspection of the medication at Nasar's review meeting in May 2016. That is a matter of very deep regret. All of CWB's school nurses receive 'Health Care Plan' t raining as provided by CWB which specifically covers the requirements for reviewing medication and how and when this must be undertaken. The Nurse in this case attended that training in June 2015 and we have attempted to understand whether the failure was an individual one or is wider. We have established that the Nurse had previously undertaken two periods of study successfully completing a practice portfolio demonstrating a knowledge and understanding of reviewing medication during a Health Care Plan meeting. We therefore believe that the Nurse was fully aware of the requirement for medication to be physically present and visually inspected at a review meeting and he should have done so in May 2016 when Nasar Ahmed's medication was reviewed. StepsTaken We have reminded all of our staff that there are no circumstances when a school nurse would not be expected to have the medication in front of them when conducting a review. Our staff have been reminded that we would consider a similar breach to be an act of gross misconduct and would also result in a professional conduct referral. To assist with ensuring that medication is visually inspected by school nurses across the service at review meetings, a checklist has also been introduced for use during Individual Health Care Plan ("IHCP") review meetings. This new measure is designed to ensure that all areas of the review process have been covered during the meeting. This new checklist will act as guidance and prompt to all school nurses and, once completed, will be scanned onto the Child's Health Record. A copy of the 'School annual review asthma/wheeze checklist' is enclosed. The completion of this checklist will form part of the bi-annual IHCP audit, further details of which are provided later in this response. Steels Lane Health Centre, 384-398 Commercial Road, El DLR Registered in England: 08451249
l' compass wellbeing As part of their investigations, CWB have undertaken a wider review of the School Health Service, records kept and IHCPs, all of which are key areas in working to ensure that IHCP and medication reviews are conducted correctly and in a t imely manner. In December 2016, CWB carried out a sample audit of IHCPs to review a cross-section of IHCPs and identify any areas that required improvement across the service. The findings showed that the IHCPs were of a good standard overall. During this review, there were examples of high standards of documented care however, it was noted that there was a lack of consistency across practitioners in terms of recording and articulating details of care plan meetings. As a result of this sample audit, it was identified that there was a need for a more robust approach ensuring that all children requiring an IHCP have one that is in date and fully and consistently detailing the support required; including a particular focus on identifying what action is to be taken in the event of an emergency. An IHCP improvement plan was subsequently implemented to identify, review and monitor all IHCPs across the service using a centralised database. This will support the identification of IHCPs requiring review which will be automatically flagged to the senior management team by an identified data manager. The database has been designed with a flagging system in it. The system counts down in days when an IHCP is due to be renewed and turns the date yellow 60 days prior to the expiry date and red once the date has arrived. The database will be managed by a data team on a daily basis and details of IHCP due (within 60 days) sent via email to the individual nurse responsible for the school and their line manager. This will be overseen by the clinical lead for the service and monitored as part of the performance data for the service. A full Quality Standards Audit was commenced in June 2017 for IHCPs and is due to be completed in August 2017. This audit will review all IHCPs across the whole service. Once this audit has been completed, the annual audit schedule will be extended to include IHCP audits on a bi-annual basis. We will put in place a robust action plan to deal with any deficiencies identified. CWB has also fully reviewed and identified the training received by school nurses and what they are required to receive in order to complete IHCPs in line with CWB's Competency Framework. The Competency Framework is a learning and development resource for nurses and this is completed upon their induction to the service. Re-training has been delivered in line with this Competency Framework. IHCP training has also been undertaken by all staff on 22 June 2017 in order to re-emphasise the role of a qualified nurse with reference to the guidance and the support of administering medication by non- Steels Lane Health Centre, 384-398 Commercial Road, El OLR Registered in England: 08451249
l' compass wellbeing registered (NMC) individuals. As part of the re-training exercise staff were told of the tragic events of this case. In addition to the above training, the bi-annual training received by the school nursing service was delivered in June 2017. During bi-annual training, the service is suspended and training takes place across all staff groups. The training has been tailored to support the key learning points from the tragic death of Nasar Ahmed and the requirements and expectations of a school nurse. It covered a range of key areas including how to improve record keeping and the importance of this, the increased function of school nurse administrators in communication and following up actions with key staff in school and the parents, the use of electronic diary systems and diary management. A copy of the training schedule undertaken in June 2017 is attached. Specific IHCP training will continue to take place on a bi-annual basis. The next scheduled training is for September 2017. We believe that there is now in place a rigorous and proactive approach to auditing, reviewing and monitoring of IHCPs and we are determined to re-enforce the correct medication review process is followed by all of our staff.
2. Although Nasar's mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting CWB recognises and understands the importance of the collaborative working arrangements involved in preparing IHCPs and the ongoing support, communication and processes for children in schools with medical conditions. The Supporting Medical Needs Policy clearly sets out that a number of organisations have roles and responsibilities and that school staff, school nurses and parents must work in partnership to ensure that the needs of pupils with medical conditions are met effectively. Steps Taken Following Nasar's sad death CWB have prepared a Partnership Agreement between CWB and schools across the Borough of Tower Hamlets. This agreement sets out arrangements for support and training for education staff, as well as detailing the expectations across the organisational boundaries. Page 7 of the Agreement (copy enclosed) outlines the roles and responsibilities of the School Health Service and the school. It specifically requires that a member of staff will be identified who will liaise with the School Health Service. The identified school staff member is the person responsible for that child and who has Steels Lane Health Centre, 384-398 Commercial Road, El DLR Registered in England: 08451249
compass wellbeing the appropriate levels of authority to agree possible actions generated from an IHCP and who is able to disseminate information regarding the child's care across the school, including what to do in an emergency. The staff member will work to ensure support and consistency is provided by the school and School Health Service, particularly in relation to the creation of IHCPs and attendance at review meetings. CWB is currently working with the London Borough of Tower Hamlets Public Health and Education departments, as well as Tower Hamlets head teachers representatives, to finalise and roll out the agreements across all schools. Alongside this, joint letters have been sent to all school head teachers within the Borough of Tower Hamlets detailing how schools can become "asthma friendly". This also out lines the expectations and requirements of the school and the School Health Service. This has been prepared and sent in partnership with the specialist teams led by (from whom you heard evidence at the inquest). Furthermore, as part of this partnership, CWB with the assistance of the respiratory clinical nurse specialist, has revised an asthma plan template for children and a process for sharing individual asthma plans with the school nursing service and schools has been commenced. A child's individual asthma plan created by the GP/practice nurse or the specialist team will now be sent directly through to the School Health Service via secure generic email accounts. These email accounts are monitored on a daily basis. The plan will be attached to the child's health record and an email alert sent to the relevant school nurse. Training has been given to our staff team. In addition, school nurses are being supported to actively encourage appropriate members of education staff in the schools to be present during IHCP meetings. All school nurses are aware of the draft Partnership Agreement (see above) which states that there is a requirement for a school staff member to be present at these meetings. With the support of senior managers, school nurses will work to encourage the presence of school staff in IHCP meetings. CWB has also initiated a Project Plan for an incident reporting system called the 'Radar Incident Reporting System'. This system is used to record incidents and risks within the organisation and also highlights where communication difficulties occur, including where IHCP meetings need to be postponed due to non-attendance of education staff. The Radar Healthcare risk register will enable CWB to fully record and manage the major risks to the organisation and t he objectives that they compromise. Risks are prioritised and can be linked to existing incidents and complaints that have been recorded. The system allows regional and corporate risk registers to be managed, with actions, alerts and reviews being tracked to ensure effective risk management. Steels Lane Health Centre, 384-398 Commercial Road, El OLR Registered in England: 08451249
l' compass wellbeing The automated workflow and alert system for each event type ensures that there is a consistent approach to reporting, recording and managing events through the use of electronic event recording forms. Once completed, the event forms generate workflows including identifying reporting lines and governance arrangements and incorporating configured templates to help in performing effective investigations, root cause analysis and trend reporting. The project is being implemented in a number of phases which are set out at page 3 of the attached document. Phase 2 and the training on the use of the Radar system is to be undertaken in August 2017 and it is expected that once Phases 3 and 4 are completed in early September 2017, the system will be fully rolled out to all staff for use. These steps have been taken to ensure that all those involved in the effective care and support of children in schools with medical conditions work effectively and collaboratively and that there is an identified member of staff within each school to play a pro-active part in the preparation and updating of IHCPs and to attend review meetings.
3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar's medication box contained an EpiPen without any description of when or how to use it In evidence to you the Nurse accepted that he used the incorrect care plan. CWB's investigation has concluded that the Nurse had not reviewed the previous IHCP from October 2014 marked "Allergy Action Plan (Severe with Asthma)" or the updated April 2015 IHCP, again marked "Allergy Action Plan (Severe with Asthma)". Both of these previous plans were readily available to the Nurse as they had been uploaded to the EMIS (the electronic health record system} to which he had access. Paper records were also made available to him. When a school nurse is preparing to review an IHCP, it is established practice that they should go onto the EMIS and review the previous IHCP. This did not happen on this occasion. It has further been accepted by the Nurse that even if he did not have access to or see the previous plans, he should have completed the "Allergy Action Plan {Severe with Asthma)" for Nasar Ahmed based on the information he had available to him at the time. As part of CWB's investigation, each of the IHCPs prepared by this Nurse at Bow School were reviewed. CWB's investigation found that other IHCPs prepared by the Nurse had errors in them and were required to be re-written. That process has now been completed. Steels Lane Health Centre, 384-398 Commercial Road, El OLR Registered in England: 08451249
l' compass wellbeing Steps Taken The Coroner is referred to the steps set out in response to the first concern raised and the processes that have been implemented across the service to provide assurances in relation to the auditing, quality and consistency of IHCPs prepared and completed by school nurses.
4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan wit h the dose of the relevant medication The Supporting Medical Needs Policy indicates that the responsibility of checking that in-date medication is provided is a shared one between the school itself and the school nurse. It is fully expected that the school nurse and the school would have a conversation to discuss follow-up actions arising from a meeting and appropriately diarise to check that the correct medication has been received and, if not received, to chase this up in a timely manner. As a qualified health professional, the school nurse is able and expected to understand whether a prescription is appropriate and whether the correct medication has been received. Any outstanding actions must be followed up and completed as a matter of course and in accordance with their professional duties. As referred to above, CWB has carried out an investigation into the actions of the Nurse, including his failure to diarise to ensure that the current medication was provided and in the box. As was evident from the Inquest, the investigation findings are that the Nurses' diary made no mention or record of any follow- up action relating to checking the medication. There is no evidence to show that he checked the medication had been received and was in Nasar Ahmed's box and that is a matter of very deep regret. Steps Taken CWB have implemented additional measures to ensure that the checking and updating of actions from IHCP meetings are routinely followed up by all school nurses and to prevent this event from happening again. All clinical staff have received guidance on how to manage an electronic diary in order to assist staff in diarising appointment, reminders and sharing calendar appointments. All clinical staff have access to mobile working devices, tor example laptops, and the service is moving to a fully electronic diarising system in order to support sharing of appointment calendars and the effective use of an electronic diary and reminder system. Specific training on electronic diarising and the use of this took place on 21 June Steels Lane Health Cent re, 384-398 Commercial Road, El OLR Registered in England: 08451249
ii compass wellbeing 2017 and we believe that the system is fully understood by our staff team. The system will be fully rolled out in the new academic year (September 2017). Furthermore, the bi-annual training referred to earlier above will also cover the use of electronic diary systems and diary management and act as a reminder of our expectations. Having an electronic diary system in place operated by trained staff will enable appointments to be clearly made and set out within the calendar and reminders and electronic prompts to be set. This will assist in ensuring that actions are followed up on a prompt and routine basis. We have told our staff that they should not be afraid of letting us know if they are struggling to 'get to grips' with the electronic system of working. CWB have re-enforced to all staff the requirement and expectation across the service to ensure that accurate and contemporaneous records are kept, including recording and documenting action points and dates for follow up, as well as documenting who is responsible for each action point. This has been re- enforced through medico-legal training which was arranged for all staff in order to address the implications of poor documentation keeping and the effect this has on the delivery of healthcare. This training took place on 19 June 2017. The requirement and importance of record keeping is also set out within CWB's Competency Framework which states that there is a need to "ensure all records are written contemporaneously and in accordance with the NMC record keeping standard and local record keeping and documentation standards and guidelines including local electronic documentation, storage and deletion policies". As referred to previously within this response, this is a framework reviewed and completed by school nurses upon their induction to CWB. Whilst we wish to avoid repetition we confirm that training in relation to this framework and the relevant competencies has been re-run. We hope that this response provides clear and substantive evidence of the actions taken by CWB to prevent future deaths. However, should you require any further information or clarification, please do not hesitate to contact us.
Disputed
The London Ambulance Service (LAS) disputes the coroner's concern, stating that the Clinical Hub paramedic did not advise against using the EpiPen and that the call was appropriately managed and the LAS will take no action. (AI summary)
The London Ambulance Service (LAS) disputes the coroner's concern, stating that the Clinical Hub paramedic did not advise against using the EpiPen and that the call was appropriately managed and the LAS will take no action. (AI summary)
View full response
Dear Ms Hassell Regulation 28; Prevention of Future Deaths Report arising from the inquest into the death of Nasar AHMED Thank you for your Regulation 28 Report dated 21 April 2017 bringing to my attention matters of concern. As there had been no concerns raised with the London Ambulance Service NHS Trust (LAS) prior to the inquest we were surprised and disappointed to receive this Regulation 28 Report. I note the concern raised is stated as follows: While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious. It is unfortunate that LAS were not made an Interested Person for the inquest and as a result we did not receive the benefit of full disclosure of documents. LAS were also not asked to provide any information or documents relating to call handling or to confirm what advice had been given by the Clinical Hub paramedic nor were we informed of any concerns in this respect. Had we been given this opportunity we would have been able to provide you with the necessary information and we would also have offered the court a senior clinician to provide evidence at the inquest to clarify exactly what advice was given by the Clinical Hub paramedic and why, which I believe would have been of benefit to the court and Nasar’s family in the circumstances. Please find attached a transcript of the call CAD 2463 from 10th November 2016. It is clearly documented in the transcript that the caller from Bow school was unable to provide to both the LAS call handler and the Clinical Hub paramedic details as to what Nasar’s clinical condition was. Page 2 of the transcript confirms that the caller informed the call handler that they had an EpiPen and it had just been used. The call handler repeatedly asks the caller to advise what Nasar’s condition is and the caller is unable to provide clear details on whether he had allergies or asthma. As a result the call handler correctly seeks the assistance of a paramedic on the Clinical Hub, as call handlers are not clinicians. The handover from the call handler to the Clinical Hub paramedic detailed on page 4 of the transcript, details the call handler explaining to
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the Clinical Hub paramedic that the caller is not able to say what Nasar’s condition is and that they are requesting advice on the use of the EpiPen. On page 5 you will note that the paramedic takes the caller through a series of questions to determine with as much clarity as is possible when one is not on scene with the patient, what Nasar’s history was and his clinical presentation at that time. At no point does the paramedic advise the caller not to use an EpiPen. The conversation between the caller and the Clinical Hub paramedic lasts for less than one minute and before the Clinical Hub paramedic had finished asking the necessary questions, the ambulance crew arrived on scene and the Clinical Hub paramedic correctly left Nasar in the care of the on scene crew. I note from the Regulation 28 Report that the opinion given by the respiratory paediatrician who gave evidence at the inquest was that the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately. Given that the Clinical Hub paramedic was not clear on Nasar’s condition or when Nasar had last had the EpiPen, if at all, it was not unreasonable for the Clinical Hub paramedic to spend a few moments trying to establish the facts. The process of eliciting the necessary information was almost concurrent with the first paramedic arriving on scene. The audio recording of the inquest has been listened to by our Legal Services Department and I am advised that the evidence of the staff at Bow School was that they asked the LAS (call handler and Clinical Hub paramedic) if they should give the EpiPen but they did not get an answer. This is rather different to being told not to use an EpiPen, which was not the advice given by LAS. It is our conclusion that the call was appropriately managed by the call handler in trying to elicit the necessary information and it is clear from the transcript provided to you that the Clinical Hub paramedic did not advise Bow School not to use the EpiPen. I hope that this reply will be helpful in clarifying the confusion over the advice given by the LAS on the use of the EpiPen. On the basis of the reasoning set out in this response, LAS propose to take no action in respect of the concern raised in the Regulation 28 Report. This Regulation 28 response will be shared with the Association of Ambulance Chief Executives and the National Ambulance Service Medical Directors. Finally in closing, I should like to offer my sincere condolences to Nasar’s family.
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the Clinical Hub paramedic that the caller is not able to say what Nasar’s condition is and that they are requesting advice on the use of the EpiPen. On page 5 you will note that the paramedic takes the caller through a series of questions to determine with as much clarity as is possible when one is not on scene with the patient, what Nasar’s history was and his clinical presentation at that time. At no point does the paramedic advise the caller not to use an EpiPen. The conversation between the caller and the Clinical Hub paramedic lasts for less than one minute and before the Clinical Hub paramedic had finished asking the necessary questions, the ambulance crew arrived on scene and the Clinical Hub paramedic correctly left Nasar in the care of the on scene crew. I note from the Regulation 28 Report that the opinion given by the respiratory paediatrician who gave evidence at the inquest was that the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately. Given that the Clinical Hub paramedic was not clear on Nasar’s condition or when Nasar had last had the EpiPen, if at all, it was not unreasonable for the Clinical Hub paramedic to spend a few moments trying to establish the facts. The process of eliciting the necessary information was almost concurrent with the first paramedic arriving on scene. The audio recording of the inquest has been listened to by our Legal Services Department and I am advised that the evidence of the staff at Bow School was that they asked the LAS (call handler and Clinical Hub paramedic) if they should give the EpiPen but they did not get an answer. This is rather different to being told not to use an EpiPen, which was not the advice given by LAS. It is our conclusion that the call was appropriately managed by the call handler in trying to elicit the necessary information and it is clear from the transcript provided to you that the Clinical Hub paramedic did not advise Bow School not to use the EpiPen. I hope that this reply will be helpful in clarifying the confusion over the advice given by the LAS on the use of the EpiPen. On the basis of the reasoning set out in this response, LAS propose to take no action in respect of the concern raised in the Regulation 28 Report. This Regulation 28 response will be shared with the Association of Ambulance Chief Executives and the National Ambulance Service Medical Directors. Finally in closing, I should like to offer my sincere condolences to Nasar’s family.
Action Taken
BSACI has produced national guidelines for managing various allergies, promotes written personalized emergency management plans, and has been part of a campaign to allow schools to hold spare adrenaline auto-injectors, with revised regulations coming into effect on 1 October 2017, and is developing a website to support school staff. (AI summary)
BSACI has produced national guidelines for managing various allergies, promotes written personalized emergency management plans, and has been part of a campaign to allow schools to hold spare adrenaline auto-injectors, with revised regulations coming into effect on 1 October 2017, and is developing a website to support school staff. (AI summary)
View full response
British Society for Allergy and Clinical Immunology Studio 16, Cloisters House, 8 Battersea Park Road, London SWB 4BG Tel: +44 (0) 207 501 3910 bsaci Fax: +44 (0) 207 627 2599 improving allergy care Email: info@bsaci.org through education, training and research Website: www.bsaci.org To: Coroner M E Hassell Senior Coroner Inner North London St Pancras Coroner's Court Carnley Street London IC 4PP 13 JUL 2017 I Tuesday July 11th. 2017 Rcgulntion 28: Prevention of Future Deaths Report: Re: lnqucstintothedcath ofNasarAHMED (dicd 14.11.16) Thank you for forwarding a cop} of the investigation into the death of asar Ahmed. You have asked me. as President of BSACI. to respond to your report and to set out details ofaction taken or proposed to be taken in response to your report. The British Societ) for Allergy and Clinical Immunology (BSACI) is the society that represents professionals who work within the field of Allergy in the UK. BSACI has a long track record of providing resources 10 both our members and to the wider professional community to support practice in dealing with allergic conditions. The circumstances around Nasar's death are 1101 novel to this Society and, therefore, for many years we have provided guidance in order 10 reduce the risk ofsimilar cases in the furure. We have produced a number of national guidelines using a process accredited by N JCE (National Institute of Care Excellence) and these include the following: I. BSACI Guidelines for the Management or Egg Allergy (20 I 0)
2. BSACI Guidelines for Diagnosis and Management ofCows Milk Allergy (2014)
3. BSACI Guidelines on Adrenaline Auto-injectors (2016)
4. BSACI Guidelines on the Diagnosis and Management of ul Allergy (2017) In addition. we have promoted 1he use of wriucn personalised emergency 111anagcmcn1 plans for anaphyl~ctic reactions. We have developed templates which can be used by all hcallhcare professionals available on the BSACI wcbstte and these can be tailored to each individual 's personal circumstances and allergies. BSACI have also been pa11 of a campaign 10 ensure that schools cnn hol? _spare adreln~linc aAuto~Onjl~cto~;\~:~:1~1~/~~:~:!'i:~: · · · d d 1 10 the Human Medicines Re0 u at1ons Ct -
-· for use in emergencies. This require an amen men . . k/:d/ ko '/2017/7 15) The revised regulations will week that the amendment has been accepted (hnp://www.leg1slat10n.~ov.u I"• u
-injectors .without prescri1ltion for use in ·11 II hools to buy a rcna me au -
• . d come into elTect on I October ~0 17 an _w1. a. ow sc .. , . . vidcd it is done on an occasional basis and not for pro ht. emergencies from a pharmaceutical supplier Ill small qua~111tu.:: J)IO I. I will provide online resources to suppon school staff Furthermore a working group has been set up 10 develop ,1 we s11e " 11c l with this. Ir you would like to discuss the contents of my . . . th sc BSACI initiatives is available on www.bsaci.org. Further mforrnat1on on e letter I would be pleased to speak to you. With kind regards
2. BSACI Guidelines for Diagnosis and Management ofCows Milk Allergy (2014)
3. BSACI Guidelines on Adrenaline Auto-injectors (2016)
4. BSACI Guidelines on the Diagnosis and Management of ul Allergy (2017) In addition. we have promoted 1he use of wriucn personalised emergency 111anagcmcn1 plans for anaphyl~ctic reactions. We have developed templates which can be used by all hcallhcare professionals available on the BSACI wcbstte and these can be tailored to each individual 's personal circumstances and allergies. BSACI have also been pa11 of a campaign 10 ensure that schools cnn hol? _spare adreln~linc aAuto~Onjl~cto~;\~:~:1~1~/~~:~:!'i:~: · · · d d 1 10 the Human Medicines Re0 u at1ons Ct -
-· for use in emergencies. This require an amen men . . k/:d/ ko '/2017/7 15) The revised regulations will week that the amendment has been accepted (hnp://www.leg1slat10n.~ov.u I"• u
-injectors .without prescri1ltion for use in ·11 II hools to buy a rcna me au -
• . d come into elTect on I October ~0 17 an _w1. a. ow sc .. , . . vidcd it is done on an occasional basis and not for pro ht. emergencies from a pharmaceutical supplier Ill small qua~111tu.:: J)IO I. I will provide online resources to suppon school staff Furthermore a working group has been set up 10 develop ,1 we s11e " 11c l with this. Ir you would like to discuss the contents of my . . . th sc BSACI initiatives is available on www.bsaci.org. Further mforrnat1on on e letter I would be pleased to speak to you. With kind regards
Action Planned
Barts Health NHS Trust will implement an action plan, work with partners on the Asthma Friendly Schools Project, promote the Healthy London Partnership Paediatric asthma toolkit, improve knowledge of long-term conditions in childhood, and standardize asthma management across Tower Hamlets in line with London Paediatric Asthma standards. (AI summary)
Barts Health NHS Trust will implement an action plan, work with partners on the Asthma Friendly Schools Project, promote the Healthy London Partnership Paediatric asthma toolkit, improve knowledge of long-term conditions in childhood, and standardize asthma management across Tower Hamlets in line with London Paediatric Asthma standards. (AI summary)
View full response
Dear Dr. Hassell, I am writing in response to the Regulation 28 (Prevention of Future Deaths) report into the death of Nasar Ahmed. First and foremost our thoughts are with Nasar's family in what must be a very difficult time for them. We also recognise that Nasar's death has had a significant impact on health and education professionals across Tower Hamlets and that the teams treating Nasar at the Royal London Hospital have been deeply affected by it. We have considered the circumstances around Nasar Ahmed's death and each of the concerns you raise. We have addressed these concerns in the form of an action plan attached. In addition to actions addressing the concerns specified in your report we will work with partners to fulfil the following system wide actions: Implementation of the Asthma Friendly Schools Project Universal use of the Healthy London Partnership Paediatric asthma toolkit for training staff across health and education. Enhanced knowledge of long term conditions in childhood to improve health, education and individuals self-management of chronic health prqblems.
r~t:bj Barts Health NHS Trust Standardisation of acute and chronic asthma management across Tower Hamlets in line with the London Paediatric Asthma standards and incorporating the NICE quality standard and the proposed diagnosis and management standard to be published October 2017. This work will be supported by the North East London Children and Young People's Asthma Alliance. I trust that our response addresses your concerns and that the action plan supports the prevention of future deaths from acute asthma and anaphylaxis. If there is any further information you require please do not hesitate to contact me.
r~t:bj Barts Health NHS Trust Standardisation of acute and chronic asthma management across Tower Hamlets in line with the London Paediatric Asthma standards and incorporating the NICE quality standard and the proposed diagnosis and management standard to be published October 2017. This work will be supported by the North East London Children and Young People's Asthma Alliance. I trust that our response addresses your concerns and that the action plan supports the prevention of future deaths from acute asthma and anaphylaxis. If there is any further information you require please do not hesitate to contact me.
Action Taken
The practice discussed the case as a team, reviewed individual consultations, contacted the pharmacy, and contacted the safeguarding team and hospital respiratory team for learning; the nursing team will now post/email a copy of the asthma action plan to the child’s school health team or give a copy to parents to hand in, starting July 2017; the nursing team will investigate anaphylaxis care plans in secondary care and incorporate them into care plans by September 2017. (AI summary)
The practice discussed the case as a team, reviewed individual consultations, contacted the pharmacy, and contacted the safeguarding team and hospital respiratory team for learning; the nursing team will now post/email a copy of the asthma action plan to the child’s school health team or give a copy to parents to hand in, starting July 2017; the nursing team will investigate anaphylaxis care plans in secondary care and incorporate them into care plans by September 2017. (AI summary)
View full response
St Andrews Health Centre 2 Hannaford Walk London, E3 3FF Tel: 020 8980 1888 Fax: 020 8980 2753
Partnership
The Bromley by Bow Health Partnership Creating Healthy Communities
02-Jul-2017 Coroner ME Hassell Senior Coroner Inner north London St Pancras Coroners court Camley Street London NC1 4PP
Response to the Prevention of future deaths report following the death of Nasar Ahmed
I am writing to you on behalf of Bromley by Bow health partnership in response to the matters of concerns raised by the coroner’s inquest in the 'prevention of future deaths report' following the death of Nasar Ahmed.
We have been deeply saddened by the events and death of this child and the impact it will have had on the family- our thoughts are with them.
Following the events that have occurred, these are just some of the steps we have taken:
- We have discussed the case multiple times as a team and taken steps as a team to identify areas of good practice and areas for learning.
- We have discussed the case individually with all those involved in Nasar's care (nurses, GPs, clinical pharmacist) and each consultation has been thoroughly reviewed.
- We have contacted the pharmacy he collected medication from to discuss the matter and improve our understanding.
- We have been in contact with the borough safeguarding team to provide information in order to support discussion at the serious case review panel for further learning.
- We have also been in contact with the hospital paediatric respiratory team to arrange a meeting for further learning.
I will now specifically respond to the 4 main points raised in turn.
St Andrews Health Centre
2 Hannaford Walk London, E3 3FF Tel: 020 8980 1888 Fax: 020 8980 2753
Partnership
The Bromley by Bow Health Partnership Creating Healthy Communities
Point 1 states that Nasar's report of symptoms to his consultant didn't correlate with the GPs findings, that his lung function tests were good, that GP prescribed 30 inhalers which is a recognised risk factor for death and that he should have been seen by the consultant again. The point queries whether an automatic flag could be raised if excess medication is prescribed.
There is already a mechanism in place via our Emis patient records system which flags a pop up alert anytime excess short acting beta agonist inhaler prescriptions are given- this is if more than 12 are issued in the last 12 months. The patient is flagged as high risk and if we haven't already, we would contact the patient/parent to book in for an asthma review.
These patients also get flagged up on our recall list for ‘enhanced asthma review’. We currently run searches for those deemed as high risk patients (i.e. those that have a high use of SABA inhalers more than 6 per year, more than 2 asthma exacerbations per year, recent hospital or A&E attendance or high dose inhaled steroid therapy) and proactively invite these patients for review as a priority for enhanced asthma reviews.
Nasar was proactively invited for an enhanced review as he was flagged up in such a way demonstrating that the flag does pick up such patients. This review took place on 15th Feb 2016 and this is where he was discovered to have poor inhaler technique. Time was spent teaching him the correct technique for his preventer and reliever medication. The report suggests he should have been seen by the consultant again. He did indeed get seen 5 days after this consultation in a consultant clinic. On 19th Feb he was seen by a specialist registrar. We believe that the registrar did not flag him up as a high risk patient because following the correction of his inhaler technique by our team, his symptoms and lung function tests were much better. He had further follow up appointments organised by us after this in March and it did in fact show that his asthma control score had improved to 24/25. Nasar was invited again in August 2016 proactively for another enhanced asthma review. Our notes indicate that our recall team called the family and reminded Dad the day before that Nasar had an appointment for the on 31st august. The clinician conducting the consultation also called prior to the appointment to remind family to bring in inhalers so that inhaler technique could be checked again, unfortunately, these were forgotten by the family and so a note was made by the clinician that the inhaler technique needs to be checked again at next follow up. At this point, the Asthma test score was again 14/25. There was no specified time period for follow up or review. However, there was a further entry on 14th
St Andrews Health Centre
2 Hannaford Walk London, E3 3FF Tel: 020 8980 1888 Fax: 020 8980 2753
Partnership
The Bromley by Bow Health Partnership Creating Healthy Communities
October 2016 in the notes where we contacted the parents to come in for a medication review with a GP.
On review of the literature, there is no specified guidance about what actions should be taken with different levels of asthma test scores- just that a score less than 20 may indicate poorly controlled asthma. Further national level guidance on this may be useful to avoid variations in action. At a clinical team meeting on 27th June 2017, we reflected on the point that at Nasar’s August 2016 asthma review, there was no follow up specified for the patient on finding that his asthma test score was 14/25. It was agreed that all clinicians must document specified follow up if the asthma test score is found to be suboptimal (i.e. <20/25). Who this review should be with and how soon it should take place would be agreed with the patient/parent on a case-by-case basis. This will be implemented immediately i.e. from June/July 2017. We hope this addresses all the queries raised in point 1. Whilst we believe our processes work well, following the event we have taken steps to tighten these even further.
Point 2 states that the asthma pump in Nasar's medication box was an accuhaler which is inappropriate for an emergency situation and that the appropriate inhaler should have been prescribed with a spacer. You wonder whether there is a wide spread lack of understanding about this.
As a team, we have reviewed national and local guidance around appropriate prescriptions of inhaler devices. We have discussed this with nurses, specialist pharmacists and the rest of our clinical team. The guidance suggests, and widespread practice is, to prescribe the inhaler type that best suits the child. In Nasar's case this was an accuhaler. We could not find any guidance that those prescribed an accuhaler for preventer use should also be prescribed a metered dose inhaler with an aerochamber to be kept at home/school for emergencies. Furthermore, throughout all his specialist hospital reviews, this was not a suggestion made by our paediatric respiratory specialists.
We reviewed BTS/Sign guidelines 2016 and the national review of asthma deaths audit
2014. BTS/SIGN (2016) stated:
Specific evidence about the pharmacological management of adolescents with asthma is limited and is usually extrapolated from paediatric and adult studies. Specific evidence about inhaler device use and choice in adolescents is also limited.
St Andrews Health Centre
2 Hannaford Walk London, E3 3FF Tel: 020 8980 1888 Fax: 020 8980 2753
Partnership
The Bromley by Bow Health Partnership Creating Healthy Communities
INHALER DEVICES- Adolescent preference for inhaler device should be taken into consideration as a factor in improving adherence to treatment. As well as checking inhaler technique it is important to enquire about factors that may affect inhaler device use in real life settings, such as school. Consider prescribing a more portable device (as an alternative to a pMDI with spacer) for delivering bronchodilators when away from home.
On discussion we felt that it may be an expert opinion to additionally prescribe another inhaler with an aerochamber for emergency situations such as this but there isn't any broader local or national guidance that recommends this and if this is the most appropriate action, this needs to be highlighted at national level to feature in guidance so that systemic change can take place both within general practice but also at hospital level. We agree that an accuhaler is not suitable for an emergency situation where a patient may not have enough respiratory effort to take in the medication appropriately so as a practice we agreed that for patients using accuhalers, we would issue an MDI with spacer for use in emergencies and make it clear what this is for in the asthma review. This will be implemented from July 2017.
Point 3 suggests that there must be a way of ensuring that a school care plan is accurate, up to date and that there are identical copies stored at home, school, GP surgery and within hospital records.
We are currently in contact with our borough children’s safeguarding team to determine whether School nurses have access to the community version of our patient record system so that information about care plans can be input into this and this can be shared between us and the school nurses. Some hospital departments also have limited access to our patient record system- this may be a good way to share information. There needs to be borough wide (and national consideration around this). From a practice level, our clinical teams are checking for up to date and accurate care plans during asthma reviews- however, this case has further highlighted the importance of this.
As a practice, we have agreed that our nursing team (who conduct the majority of our asthma reviews) will post/email a copy of the asthma action plan to the child’s school health team and/or a copy will be given to parents to hand into the school. This change will be implemented from July 2017.
Point 4 asks if there is a way of disseminating info more widely around the appropriate indications and use of IM adrenaline.
St Andrews Health Centre
2 Hannaford Walk London, E3 3FF Tel: 020 8980 1888 Fax: 020 8980 2753
Partnership
The Bromley by Bow Health Partnership Creating Healthy Communities
All our staff receives yearly BLS training and training around anaphylaxis. During this training the points above may or may not be emphasised by the trainer. We would share our learning around this at borough wide level with the safeguarding children team and discuss whether change can be implemented such that trainers organised to deliver this training emphasise the points highlighted if they also agree with these. By the end of September 2017, our nursing team will investigate whether there are anaphylaxis care plans that are already in place and being used by secondary care. We will then be incorporating these into care plans when seeing patients with asthma and allergies who have adrenaline prescriptions.
I hope all your points have been addressed. We are keen to work with all willing partners to improve the care of patients with asthma and will be happy to provide any further information as required.
Regards
GP Partner – Bromley by Bow health partnership
Partnership
The Bromley by Bow Health Partnership Creating Healthy Communities
02-Jul-2017 Coroner ME Hassell Senior Coroner Inner north London St Pancras Coroners court Camley Street London NC1 4PP
Response to the Prevention of future deaths report following the death of Nasar Ahmed
I am writing to you on behalf of Bromley by Bow health partnership in response to the matters of concerns raised by the coroner’s inquest in the 'prevention of future deaths report' following the death of Nasar Ahmed.
We have been deeply saddened by the events and death of this child and the impact it will have had on the family- our thoughts are with them.
Following the events that have occurred, these are just some of the steps we have taken:
- We have discussed the case multiple times as a team and taken steps as a team to identify areas of good practice and areas for learning.
- We have discussed the case individually with all those involved in Nasar's care (nurses, GPs, clinical pharmacist) and each consultation has been thoroughly reviewed.
- We have contacted the pharmacy he collected medication from to discuss the matter and improve our understanding.
- We have been in contact with the borough safeguarding team to provide information in order to support discussion at the serious case review panel for further learning.
- We have also been in contact with the hospital paediatric respiratory team to arrange a meeting for further learning.
I will now specifically respond to the 4 main points raised in turn.
St Andrews Health Centre
2 Hannaford Walk London, E3 3FF Tel: 020 8980 1888 Fax: 020 8980 2753
Partnership
The Bromley by Bow Health Partnership Creating Healthy Communities
Point 1 states that Nasar's report of symptoms to his consultant didn't correlate with the GPs findings, that his lung function tests were good, that GP prescribed 30 inhalers which is a recognised risk factor for death and that he should have been seen by the consultant again. The point queries whether an automatic flag could be raised if excess medication is prescribed.
There is already a mechanism in place via our Emis patient records system which flags a pop up alert anytime excess short acting beta agonist inhaler prescriptions are given- this is if more than 12 are issued in the last 12 months. The patient is flagged as high risk and if we haven't already, we would contact the patient/parent to book in for an asthma review.
These patients also get flagged up on our recall list for ‘enhanced asthma review’. We currently run searches for those deemed as high risk patients (i.e. those that have a high use of SABA inhalers more than 6 per year, more than 2 asthma exacerbations per year, recent hospital or A&E attendance or high dose inhaled steroid therapy) and proactively invite these patients for review as a priority for enhanced asthma reviews.
Nasar was proactively invited for an enhanced review as he was flagged up in such a way demonstrating that the flag does pick up such patients. This review took place on 15th Feb 2016 and this is where he was discovered to have poor inhaler technique. Time was spent teaching him the correct technique for his preventer and reliever medication. The report suggests he should have been seen by the consultant again. He did indeed get seen 5 days after this consultation in a consultant clinic. On 19th Feb he was seen by a specialist registrar. We believe that the registrar did not flag him up as a high risk patient because following the correction of his inhaler technique by our team, his symptoms and lung function tests were much better. He had further follow up appointments organised by us after this in March and it did in fact show that his asthma control score had improved to 24/25. Nasar was invited again in August 2016 proactively for another enhanced asthma review. Our notes indicate that our recall team called the family and reminded Dad the day before that Nasar had an appointment for the on 31st august. The clinician conducting the consultation also called prior to the appointment to remind family to bring in inhalers so that inhaler technique could be checked again, unfortunately, these were forgotten by the family and so a note was made by the clinician that the inhaler technique needs to be checked again at next follow up. At this point, the Asthma test score was again 14/25. There was no specified time period for follow up or review. However, there was a further entry on 14th
St Andrews Health Centre
2 Hannaford Walk London, E3 3FF Tel: 020 8980 1888 Fax: 020 8980 2753
Partnership
The Bromley by Bow Health Partnership Creating Healthy Communities
October 2016 in the notes where we contacted the parents to come in for a medication review with a GP.
On review of the literature, there is no specified guidance about what actions should be taken with different levels of asthma test scores- just that a score less than 20 may indicate poorly controlled asthma. Further national level guidance on this may be useful to avoid variations in action. At a clinical team meeting on 27th June 2017, we reflected on the point that at Nasar’s August 2016 asthma review, there was no follow up specified for the patient on finding that his asthma test score was 14/25. It was agreed that all clinicians must document specified follow up if the asthma test score is found to be suboptimal (i.e. <20/25). Who this review should be with and how soon it should take place would be agreed with the patient/parent on a case-by-case basis. This will be implemented immediately i.e. from June/July 2017. We hope this addresses all the queries raised in point 1. Whilst we believe our processes work well, following the event we have taken steps to tighten these even further.
Point 2 states that the asthma pump in Nasar's medication box was an accuhaler which is inappropriate for an emergency situation and that the appropriate inhaler should have been prescribed with a spacer. You wonder whether there is a wide spread lack of understanding about this.
As a team, we have reviewed national and local guidance around appropriate prescriptions of inhaler devices. We have discussed this with nurses, specialist pharmacists and the rest of our clinical team. The guidance suggests, and widespread practice is, to prescribe the inhaler type that best suits the child. In Nasar's case this was an accuhaler. We could not find any guidance that those prescribed an accuhaler for preventer use should also be prescribed a metered dose inhaler with an aerochamber to be kept at home/school for emergencies. Furthermore, throughout all his specialist hospital reviews, this was not a suggestion made by our paediatric respiratory specialists.
We reviewed BTS/Sign guidelines 2016 and the national review of asthma deaths audit
2014. BTS/SIGN (2016) stated:
Specific evidence about the pharmacological management of adolescents with asthma is limited and is usually extrapolated from paediatric and adult studies. Specific evidence about inhaler device use and choice in adolescents is also limited.
St Andrews Health Centre
2 Hannaford Walk London, E3 3FF Tel: 020 8980 1888 Fax: 020 8980 2753
Partnership
The Bromley by Bow Health Partnership Creating Healthy Communities
INHALER DEVICES- Adolescent preference for inhaler device should be taken into consideration as a factor in improving adherence to treatment. As well as checking inhaler technique it is important to enquire about factors that may affect inhaler device use in real life settings, such as school. Consider prescribing a more portable device (as an alternative to a pMDI with spacer) for delivering bronchodilators when away from home.
On discussion we felt that it may be an expert opinion to additionally prescribe another inhaler with an aerochamber for emergency situations such as this but there isn't any broader local or national guidance that recommends this and if this is the most appropriate action, this needs to be highlighted at national level to feature in guidance so that systemic change can take place both within general practice but also at hospital level. We agree that an accuhaler is not suitable for an emergency situation where a patient may not have enough respiratory effort to take in the medication appropriately so as a practice we agreed that for patients using accuhalers, we would issue an MDI with spacer for use in emergencies and make it clear what this is for in the asthma review. This will be implemented from July 2017.
Point 3 suggests that there must be a way of ensuring that a school care plan is accurate, up to date and that there are identical copies stored at home, school, GP surgery and within hospital records.
We are currently in contact with our borough children’s safeguarding team to determine whether School nurses have access to the community version of our patient record system so that information about care plans can be input into this and this can be shared between us and the school nurses. Some hospital departments also have limited access to our patient record system- this may be a good way to share information. There needs to be borough wide (and national consideration around this). From a practice level, our clinical teams are checking for up to date and accurate care plans during asthma reviews- however, this case has further highlighted the importance of this.
As a practice, we have agreed that our nursing team (who conduct the majority of our asthma reviews) will post/email a copy of the asthma action plan to the child’s school health team and/or a copy will be given to parents to hand into the school. This change will be implemented from July 2017.
Point 4 asks if there is a way of disseminating info more widely around the appropriate indications and use of IM adrenaline.
St Andrews Health Centre
2 Hannaford Walk London, E3 3FF Tel: 020 8980 1888 Fax: 020 8980 2753
Partnership
The Bromley by Bow Health Partnership Creating Healthy Communities
All our staff receives yearly BLS training and training around anaphylaxis. During this training the points above may or may not be emphasised by the trainer. We would share our learning around this at borough wide level with the safeguarding children team and discuss whether change can be implemented such that trainers organised to deliver this training emphasise the points highlighted if they also agree with these. By the end of September 2017, our nursing team will investigate whether there are anaphylaxis care plans that are already in place and being used by secondary care. We will then be incorporating these into care plans when seeing patients with asthma and allergies who have adrenaline prescriptions.
I hope all your points have been addressed. We are keen to work with all willing partners to improve the care of patients with asthma and will be happy to provide any further information as required.
Regards
GP Partner – Bromley by Bow health partnership
Sent To
Response Status
Linked responses
7 of 1
56-Day Deadline
28 Jun 2023
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 17 November 2016 I commenced an investigation into the death of Nasar Ahmed, aged 14 years. The investigation concluded at the end of the inquest today. I made a narrative determination, which I attach. I concluded that the medical cause of death was:
1a post cardiac arrest hypoxic ischaemic brain injury 1b status asthmaticus 1c anaphylaxis 2 bronchial asthma and multiple food allergies
1a post cardiac arrest hypoxic ischaemic brain injury 1b status asthmaticus 1c anaphylaxis 2 bronchial asthma and multiple food allergies
Circumstances of the Death
Nasar died following an anaphylactic reaction contributed to by his asthma, when he was in the internal exclusion room at school.
Copies Sent To
Care Quality Commission for England
, Chief Medical Officer for England
Tower Hamlets Child Death Overview Panel
, nurse, Compass Wellbeing
, headteacher, Bow School
, respiratory paediatrician, RLH
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.