Muhammed Haleem
PFD Report
All Responded
Ref: 2019-0316
Emergency services related deaths (2019 onwards)
Hospital Death (Clinical Procedures and medical management) related deaths
All 2 responses received
· Deadline: 1 Jan 2020
Coroner's Concerns (AI summary)
The NWAS system contained outdated DNA-CPR guidance for paramedics, and communication between community paediatric teams and emergency services regarding advance care plans was insufficient.
View full coroner's concerns
That information held on the NWAS system for the purpose of providing immediate guidance to paramedics was years out-of-date and was not known to or supported by the clinicians involved in this child's care at the time of his death: Whilst accept the evidence that paramedics will make a clinical decision based on the patient's presentation at the time, the fact that sought advice around the existence of a DNA-CPR indicates that it is a relevant factor in their decision-making The evidence was that the number of children living in the community with DNA-CPRs in place is small and there should be communication between the community paediatric teams and emergency services of any DNA-CPRs or Advance Care Plans that are in existence and are current:
Responses
Action Planned
NWAS acknowledges the need to improve its DNA-CPR marker system. The Trust’s EOC Governance Group has been tasked with reviewing the position and making recommendations, and an update will be provided within the next 3 months. (AI summary)
NWAS acknowledges the need to improve its DNA-CPR marker system. The Trust’s EOC Governance Group has been tasked with reviewing the position and making recommendations, and an update will be provided within the next 3 months. (AI summary)
View full response
Dear HM Area Coroner McKenna
INQUEST TOUCHING UPON THE DEATH OF MUHAMMED SAIF ABDUL HALEEM
I write further to the Regulation 28 Report which you issued against the Trust on 27 September 2019, following the conclusion of the Inquest touching upon the death of Muhammed Saif Abdul Haleem.
I understand that a copy of this response will be shared with Muhammed’s family and, on behalf of North West Ambulance Service, I wish to express my sincere condolences for their loss.
Concern Raised
You raised a concern that the information held on the NWAS system for the purpose of providing immediate guidance to paramedics was 7 years out of date and was not known to or supported by the clinicians involved in Muhammed’s care at the time of his death. You stated that the evidence was that the number of children living in the community with DNA- CPR’s is small and there should be communication between the community paediatric teams and emergency services of any DNA-CPR’s or Advance Care Plans that are in existence and are current.
Notification of a DNA-CPR
When a clinical decision is made that it would not be in the best interests of the patient to resuscitate and a DNA-CPR is put in place, NWAS receive a notification, primarily from the patient’s GP but also from hospitals, through either ERISS (Electronic Referral information Sharing System) or an Addressbase or NHS.net email account. A DNA-CPR marker would only be placed on the NWAS system against the patient’s address if a notification was received from a healthcare professional or member of staff in a healthcare setting.
A notification of a DNA-CPR via ERISS generally comes from a GP practice who will notify NWAS that a patient has been issued with a DNA-CPR and a marker is applied against the
- 2 - patient’s address. Within the notification the GP will also specify a review date which is entered into the Trust gazetteer system. An automatic email from ERISS would then be sent to whoever created the notification 10 days before the expiration date and the GP practice should inform NWAS that the DNA-CPR marker is to be extended or removed.
A notification of a DNA-CPR via Addressbase or NHS.net generally comes from a hospital or other healthcare setting who will notify NWAS that a patient has been issued with a DNA- CPR and a marker is applied against the patient’s address. A scanned copy of the DNA- CPR may also be provided, which would be archived.
It is important to make the distinction between a DNA-CPR marker and a DNA-CPR. A DNA- CPR marker is an advisory notice of the potential existence of a DNA-CPR for responding clinicians to look to locate a DNA-CPR on scene. A DNA-CPR marker would not, of itself, influence patient care but assists decision making. It does not mean that the Trust definitely will not resuscitate but is simply an indication of the patient’s likely outcome and what is best for their clinical needs. At no point would a DNACPR mentioned on a call be the only source of information for the decision to resuscitate.
Review of a DNA-CPR
The responsibility of review of a DNA-CPR remains with the patient’s referring clinician. If a DNACPR is revoked, in the same way as the agreement is communicated, NWAS would expect the GP practice to communicate the change. If this does not happen, the DNA-CPR marker on the Trust system that remains in place is a warning of the potential existence of a DNA-CPR, which directs the clinician to look for a paper copy of the DNA-CPR when on scene. NWAS policy stipulates the commencement of resuscitation until information can be confirmed. NWAS should also receive requests from GP practices to remove a DNA-CPR marker when a patient has passed away.
Action being taken
It is accepted that the NWAS needs to develop and implement a system which ensures that the NWAS is aware where DNA-CPR markers are out of date and/or require a review. The solution, however, is not a simple one. Consideration has been given to the block deletion of all DNA-CPR markers which are over 12 months old, however this will require careful consideration of the impact this may have on the wider health system and also, appropriate opportunity for the Trust to communicate with GPs and the like about the proposed action.
Your Regulation 28 report has prompted much investigation and discussion both internally and with the Trust commissioners about not only DNA-CPR markers but other markers which are maintained on the Trust’s system.
The Trust’s EOC Governance Group have been tasked with reviewing the position and making recommendations and we will provide you with an update as to progress within the next 3 months.
- 3 - I am sorry that you felt that there was cause to issue a Regulation 28 report and I hope that I have addressed you concerns by this response. If you require any additional information at this stage, please contact the NWAS Legal Services team.
INQUEST TOUCHING UPON THE DEATH OF MUHAMMED SAIF ABDUL HALEEM
I write further to the Regulation 28 Report which you issued against the Trust on 27 September 2019, following the conclusion of the Inquest touching upon the death of Muhammed Saif Abdul Haleem.
I understand that a copy of this response will be shared with Muhammed’s family and, on behalf of North West Ambulance Service, I wish to express my sincere condolences for their loss.
Concern Raised
You raised a concern that the information held on the NWAS system for the purpose of providing immediate guidance to paramedics was 7 years out of date and was not known to or supported by the clinicians involved in Muhammed’s care at the time of his death. You stated that the evidence was that the number of children living in the community with DNA- CPR’s is small and there should be communication between the community paediatric teams and emergency services of any DNA-CPR’s or Advance Care Plans that are in existence and are current.
Notification of a DNA-CPR
When a clinical decision is made that it would not be in the best interests of the patient to resuscitate and a DNA-CPR is put in place, NWAS receive a notification, primarily from the patient’s GP but also from hospitals, through either ERISS (Electronic Referral information Sharing System) or an Addressbase or NHS.net email account. A DNA-CPR marker would only be placed on the NWAS system against the patient’s address if a notification was received from a healthcare professional or member of staff in a healthcare setting.
A notification of a DNA-CPR via ERISS generally comes from a GP practice who will notify NWAS that a patient has been issued with a DNA-CPR and a marker is applied against the
- 2 - patient’s address. Within the notification the GP will also specify a review date which is entered into the Trust gazetteer system. An automatic email from ERISS would then be sent to whoever created the notification 10 days before the expiration date and the GP practice should inform NWAS that the DNA-CPR marker is to be extended or removed.
A notification of a DNA-CPR via Addressbase or NHS.net generally comes from a hospital or other healthcare setting who will notify NWAS that a patient has been issued with a DNA- CPR and a marker is applied against the patient’s address. A scanned copy of the DNA- CPR may also be provided, which would be archived.
It is important to make the distinction between a DNA-CPR marker and a DNA-CPR. A DNA- CPR marker is an advisory notice of the potential existence of a DNA-CPR for responding clinicians to look to locate a DNA-CPR on scene. A DNA-CPR marker would not, of itself, influence patient care but assists decision making. It does not mean that the Trust definitely will not resuscitate but is simply an indication of the patient’s likely outcome and what is best for their clinical needs. At no point would a DNACPR mentioned on a call be the only source of information for the decision to resuscitate.
Review of a DNA-CPR
The responsibility of review of a DNA-CPR remains with the patient’s referring clinician. If a DNACPR is revoked, in the same way as the agreement is communicated, NWAS would expect the GP practice to communicate the change. If this does not happen, the DNA-CPR marker on the Trust system that remains in place is a warning of the potential existence of a DNA-CPR, which directs the clinician to look for a paper copy of the DNA-CPR when on scene. NWAS policy stipulates the commencement of resuscitation until information can be confirmed. NWAS should also receive requests from GP practices to remove a DNA-CPR marker when a patient has passed away.
Action being taken
It is accepted that the NWAS needs to develop and implement a system which ensures that the NWAS is aware where DNA-CPR markers are out of date and/or require a review. The solution, however, is not a simple one. Consideration has been given to the block deletion of all DNA-CPR markers which are over 12 months old, however this will require careful consideration of the impact this may have on the wider health system and also, appropriate opportunity for the Trust to communicate with GPs and the like about the proposed action.
Your Regulation 28 report has prompted much investigation and discussion both internally and with the Trust commissioners about not only DNA-CPR markers but other markers which are maintained on the Trust’s system.
The Trust’s EOC Governance Group have been tasked with reviewing the position and making recommendations and we will provide you with an update as to progress within the next 3 months.
- 3 - I am sorry that you felt that there was cause to issue a Regulation 28 report and I hope that I have addressed you concerns by this response. If you require any additional information at this stage, please contact the NWAS Legal Services team.
Action Taken
Alerts have been placed on the NWAS system for all children with current advance care plans (ACP), to be reviewed annually. Archived paper notes/records for children with palliative care needs known to the Children's Community Nursing Team (CCNT) are being reviewed to ensure any ACP's are included, and the Lead Nurse at the Royal Oldham Hospital Children's A&E department has been given a list of the children known to CCNT who have ACPs to enable them to set up their own alert system. (AI summary)
Alerts have been placed on the NWAS system for all children with current advance care plans (ACP), to be reviewed annually. Archived paper notes/records for children with palliative care needs known to the Children's Community Nursing Team (CCNT) are being reviewed to ensure any ACP's are included, and the Lead Nurse at the Royal Oldham Hospital Children's A&E department has been given a list of the children known to CCNT who have ACPs to enable them to set up their own alert system. (AI summary)
View full response
Dear Ms McKenna Re: Muhammed Haleem DOD 08.12.18 write following the inquest of Muhammed Haleem: The concerns you raised after hearing all the evidence have been brought to my attention and have subsequently reviewed the Regulation 28 letter issued to Pennine Care NHS Foundation Trust: The actions the Trust will take to address these concerns are as follows: That information held on the NWAS system for the purpose of providing immediate guidance to paramedics was years out of date and was not known to or supported by clinicians involved in this child's care at the time of his death: Whilst accept the evidence that paramedics will make clinical decision based on the patient's presentation at the time, the fact that they sought advice around the existence of DNA-CPR indicates that it is relevant factor in their decision making: The evidence was that the number of children living in the community with DNA-CPR's in place is small and there should be communication between the community paediatric teams and emergency services of any DNA-CPR's or Advance Care Plans that are in existence and are current can confirm that alerts have now been placed on the NWAS system for all children who have current advance care plans (ACP) these alerts will be reviewed if any changes are made or as minimum once per year when the ACP is reviewed_ In addition, we will review archived paper noteslrecords for any children with palliative care needs known to the Children's Community Nursing Team (CCNT) on 15/11/19 to ensure that any ACP's that may have commenced before the electronic system was set up are included: Trust Headquarters: 225 Old Street; Ashton-under-Lyne, Lancashire OL6 7SR. Tel: 0161 716 3000 Fconitaery] Visit us at WWwpenninecare nhsuk COMMITTED Care` 716 Way
We have also communicated with the Lead Nurse at the Royal Oldham Hospital Children's A&E department and forwarded a list of the children known to CCNT who have ACP's to enable them to set up their own alert system: We have also communicated with the Oldham Children's unit and O&A to replicate the same system: hope that the information we have provided in terms of the actions taken offers assurance to you. Please do not hesitate to contact me should you require any further information:
We have also communicated with the Lead Nurse at the Royal Oldham Hospital Children's A&E department and forwarded a list of the children known to CCNT who have ACP's to enable them to set up their own alert system: We have also communicated with the Oldham Children's unit and O&A to replicate the same system: hope that the information we have provided in terms of the actions taken offers assurance to you. Please do not hesitate to contact me should you require any further information:
Sent To
- North west Ambulance Service
- Pennine Care NHS Trust
Response Status
Linked responses
2 of 2
56-Day Deadline
1 Jan 2020
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 21st May 2019, an investigation was commenced into the death of Muhammed Saif Abdul Haleem (dob: 12 November 2005). The investigation concluded at the end of the inquest on September 2019. The inquest determined that the medical cause of death was 1a) Unascertained. The conclusion was Natural Causes.
Circumstances of the Death
Muhammed was 13 years old at the time of his death and had been born with a severe, life-limiting neurological condition: He had congenital muscular dystrophy secondary to a gene mutation and severe learning disability. He was non-verbal and could not mobilise by himself. He had a permanent tracheostomy fitted in November 2011 and was fed via a Percutaneous Endoscopic Gastrostomy: In October 2011, when Muhammed was 6 years old, he had suffered an acute episode of severe pneumonia and received intensive care at Royal Manchester Children's Hospital. He had been discharged from hospital on 14 November 2011 and those responsible for his care were of the opinion that his death was imminent A DNA-CPR document dated 11 November 2011 was forwarded to his GP and NWAS. Following this acute episode, Muhammed's condition stabilised and after 2012, he had no further in-patient admissions. He was cared for at home and attended Special Schools: He was under the care of the Community Paediatric Team and in the last six months of his life had been seen by specialists in nephrology, orthopaedics and respiratory medicine at the Children's Hospital, condition was regarded as stable. Those involved in his care were unaware of the existence of the 2011 DNA-CPR document and heard evidence from a Consultant Paediatrician that a DNA-CPR at this time was 'totally inappropriate_ Muhammed had attended school the week before his death and heard evidence from a School Nurse who had seen him on Tuesday 4t December that he was 'really well' On Saturday 8" December Muhammed had woken in the early hours which was not unusual for him. He went to sleep at about 1Oam and was checked by his mother at 11am: When his mother tried t0 rouse him for his feed shortly after 12 noon, she discovered that he was unresponsive NWAS was called at 12:18 hours and when the first paramedic arrived at 12.24 hours, Muhammed was in asystole and there was no respiratory effort. The paramedic attempted resuscitation and was joined bY further 24th His crews who continued with resuscitation: Despite those efforts, Muhammed remained in asystole throughout and resuscitation was terminated at 12.40 hours_ During the resuscitation, the paramedics had sought advice from the NWAS Clinical Support Hub who advised that a pre-written warning was in place that resuscitation would not be in Muhammed's best interests The pre-written warning on the NWAS system was undated but had been taken from the DNA-CPR document dated 11 November 2011. found on the evidence that Muhammed's condition at the time the paramedics attended on him and the lack of response to resuscitation efforts meant that he would not have responded to further resuscitative efforts, had they been continued. Muhammed was transferred to the Royal Oldham Hospital where his death was certified at 14.40 hours on 8th December 2018.
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe each of you respectively have the power to take such action:
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.