Lauren Sandell
PFD Report
Partially Responded
Ref: 2018-0205
Coroner's Concerns (AI summary)
Confusion persists regarding responsibility for vaccinating children not covered by school programs, and the optional nature of GP vaccination services means there's no audit to identify or protect unvaccinated children.
View full coroner's concerns
In the circumstances it is my statutory to report to you: (1) There would appear to be on-going confusion about who is responsible for ensuring that those children who are not (for whatever reason), vaccinated at school, should be vaccinated before attending university. The evidence indicated that 70% to 80% of children receive the vaccination at school. This would leave 20% to 30% of children unvaccinated. The evidence indicated that GPs should primarily provide the safety net for unvaccinated children. (2)The provision of the vaccination against MenW appears to fall under an enhanced service for GPs. As this is an optional addition to the GMS contract; it is unclear whether all GP surgeries have a responsibility to capture unvaccinated children: (3) It does not appear that there is any form of audit to ensure that GP practices have in place systems to identify those children who are not captured by the school programme and to in place measures to protect children, particularly before commencing university:
Responses
Action Taken
NHS England clarified the role of Child Health Information Services (CHIS) in call and recall processes for vaccinations and highlighted improvements made since 2016, including sharing guidance algorithms and conducting region-wide audits of call/recall systems. (AI summary)
NHS England clarified the role of Child Health Information Services (CHIS) in call and recall processes for vaccinations and highlighted improvements made since 2016, including sharing guidance algorithms and conducting region-wide audits of call/recall systems. (AI summary)
View full response
Dear my
child's public health interventions, replacing 18 different child health records departments using 18 separate IT solutions in line with the new_child_health digital strategy AIl regions across England are working to improve their CHIS services, to take advantage of the emerging new technologies, and the output from the NHS strategy for IT, reducing the risk of children who are eligible being missed from calll recall activity led by GP practice. The sad death of Lauren has highlighted the importance of ensuring all aspects of the vaccination service are improved for young people and their families, and NHS England on a national basis is working to implement change to reduce risks_ If you have any other areas of clarification, please do not hesitate to contact me_ Yours sincerely, Professor Stephen Powis National Medical Director NHS England High quality care for all, now and for future generations
NHS] England OFFA RS 1948 2018 Professor Stephen Powis National Medical Director Skipton House 80 London Road Miss N Persaud SE1 6LH Senior Coroner Walthamstow Coroners Court Queens Road Walthamstow E17 8QP 24"h August 2018 Dear Miss Persaud Regulation 28 Report to Prevent Future Deaths Lauren Amelia Rose Sandell Thank you for your regulation 28 report dated 25 June 2018 concerning the death of Lauren Sandell on 2 October 2016. would like to reiterate our condolences to Lauren's family: accept narrative conclusion of the inquest that Lauren's death was avoidable, as result of the GP practice not implementing the Men ACWY immunisation programme to all of the requirements of the enhanced service specification. We are very sorry about this and our primary care team in London is working directly with the practice to ensure the same situation does not occur In your regulation 28 report you have also highlighted matters of concern for NHS England which will address in turn: There would appear to be on-going confusion about who is responsible for ensuring that those children who are not (for whatever reason), vaccinated at school, should be vaccinated before attending university. The evidence indicated that 70% to 80% of children receive the vaccination at school, This would leave 20% to 30% of children unvaccinated. The evidence indicated that GPs should primarily provide the safety net for unvaccinated children: The service specifications for Men ACWY and Child Health Information services make clear the responsibility for delivery of each aspect of the vaccination programme through school based and GP practice services_ The Men ACWY vaccine was offered routinely to adolescents in school years 9 or 10 from 2015, this replaced the existing Men C vaccine which was routinely administered to adolescents_ In addition, there were number of phased catch up programmes throughout 2015 and 2016 which were designed to ensure those up to the age of 18 were caught up and offered the vaccine in school. Those older adolescents who were not in school, such as those aged 18 years and over, and those attending university for the first time were eligible for immunisation as part of the GP enhanced service. The programme was introduced rapidly as part of an outbreak control measure It was designed to reduce carriage of the meningococcus bacteria in adolescents and to be given before the age at which the highest rates of carriage were observed: If enough High quality care for all, now and for future generations the being again.
people in adolescent community are vaccinated, it's harder for a disease to pass between people who have not been vaccinated: This is called herd immunity. In order to achieve herd immunity for the Men ACWY programme Public Health England have advised that a 70% uptake rate is sufficient; nationally the coverage for children in 9 was 82% for the school based programme. School based providers (eg community trusts, social enterprise , community partnership etc) are commissioned to offer the vaccine in every school including private and faith schools which includes the initial offer and opportunities for those that may have missed this vaccinated at another time. principal of the Men ACWY and all public health programmes is to offer the intervention to 100% of the eligible population; the uptake of the vaccination remains the choice of the individual or families. The 20-30% of childrenl young adults not vaccinated in schools therefore fall into two groups: offered and declined not offered for a variety of reasons, eg programme error or incident as in this case, not attending school, home schooled, etc GP practices continue to be commissioned as part of a service to opportunistically offer the vaccine to anyone up to the age of 25_ This includes those who may have missed the opportunity to be immunised as part of the schools based programme: those attending university for the first time those aged 10 to 25 years who have not previously received dose of Meningococcal C containing vaccine. AIlI GP practices responsibility to ensure administrative processes are in place for service delivery. The process by which a GP practice offers the vaccine to all eligible children; involves working with the Child Health Information Services (CHIS) CHIS have a role to transfer information about public health interventions, transferring this to and school based services and GP practice , for those providers to act on and deliver their services to patients CHIS services and the 'failsafe' provide are improved as part of the NHS strategy for IT, improving the paperless flow of information across organisations by 2021_
2. The provision of the vaccination against Men ACWY appears to fall under an enhanced service for GPs As this is an optional addition to the GMS contract, is unclear whether all GP surgeries have a responsibility to capture unvaccinated children: You are correct that the provision of the Men ACWY vaccine for those who no longer fall within the schools based programme is the responsibility of the GP under an enhanced service . Whilst the enhanced service is optional, GPs have the responsibility of providing the Men ACWY vaccine for their registered eligible population and must inform NHS England commissioners as soon as possible if they are not taking up the enhanced service. NHS England will then ensure that those eligible patients are offered the service by an alternative primary care provider. Those eligible for immunisation remain eligible whether or not the practice accepts the service_ It does not appear that there is any form of audit to ensure that GP practices have in place systems to identify those children who are not captured by school programme and to in place measures to protect children, particularly before commencing university. High quality care for all, now and for future generations the Year being key have the from they being the put
The Child Health Information Service (CHIS) service is the organisation locally that records whether or not a childl young person has received a vaccine or other public health interventions, and acts to support the process of capturing information, including transferring information it receives from school based services to a GP practice, who then have the responsibility to act on the information received. Each has an established system in place to ensure that GP providers are made aware of vaccinations administered by school aged vaccination providers, with regular reports on the processed within CHIS coming to a national NHS England oversight group on a quarterly basis_ NHS England is working to ensure that all those eligible for vaccinations should be offered the vaccine either in school or by a GP practice Those who may have missed the opportunity to be vaccinated, remain eligible until they are 25 years f age_ Although the case of Lauren, is an unfortunate and avoidable death, Public Health England have advised that there has been decline in Meningococcal group W cases overall in England during 2017/18, and this decline is expected to continue to reduce across all ages including in unvaccinated adolescents and children: Thank you for bringing your concerns to the attention of NHS England: hope our response provides you with reassurance that NHS England are taking proactive steps to address your concerns
child's public health interventions, replacing 18 different child health records departments using 18 separate IT solutions in line with the new_child_health digital strategy AIl regions across England are working to improve their CHIS services, to take advantage of the emerging new technologies, and the output from the NHS strategy for IT, reducing the risk of children who are eligible being missed from calll recall activity led by GP practice. The sad death of Lauren has highlighted the importance of ensuring all aspects of the vaccination service are improved for young people and their families, and NHS England on a national basis is working to implement change to reduce risks_ If you have any other areas of clarification, please do not hesitate to contact me_ Yours sincerely, Professor Stephen Powis National Medical Director NHS England High quality care for all, now and for future generations
NHS] England OFFA RS 1948 2018 Professor Stephen Powis National Medical Director Skipton House 80 London Road Miss N Persaud SE1 6LH Senior Coroner Walthamstow Coroners Court Queens Road Walthamstow E17 8QP 24"h August 2018 Dear Miss Persaud Regulation 28 Report to Prevent Future Deaths Lauren Amelia Rose Sandell Thank you for your regulation 28 report dated 25 June 2018 concerning the death of Lauren Sandell on 2 October 2016. would like to reiterate our condolences to Lauren's family: accept narrative conclusion of the inquest that Lauren's death was avoidable, as result of the GP practice not implementing the Men ACWY immunisation programme to all of the requirements of the enhanced service specification. We are very sorry about this and our primary care team in London is working directly with the practice to ensure the same situation does not occur In your regulation 28 report you have also highlighted matters of concern for NHS England which will address in turn: There would appear to be on-going confusion about who is responsible for ensuring that those children who are not (for whatever reason), vaccinated at school, should be vaccinated before attending university. The evidence indicated that 70% to 80% of children receive the vaccination at school, This would leave 20% to 30% of children unvaccinated. The evidence indicated that GPs should primarily provide the safety net for unvaccinated children: The service specifications for Men ACWY and Child Health Information services make clear the responsibility for delivery of each aspect of the vaccination programme through school based and GP practice services_ The Men ACWY vaccine was offered routinely to adolescents in school years 9 or 10 from 2015, this replaced the existing Men C vaccine which was routinely administered to adolescents_ In addition, there were number of phased catch up programmes throughout 2015 and 2016 which were designed to ensure those up to the age of 18 were caught up and offered the vaccine in school. Those older adolescents who were not in school, such as those aged 18 years and over, and those attending university for the first time were eligible for immunisation as part of the GP enhanced service. The programme was introduced rapidly as part of an outbreak control measure It was designed to reduce carriage of the meningococcus bacteria in adolescents and to be given before the age at which the highest rates of carriage were observed: If enough High quality care for all, now and for future generations the being again.
people in adolescent community are vaccinated, it's harder for a disease to pass between people who have not been vaccinated: This is called herd immunity. In order to achieve herd immunity for the Men ACWY programme Public Health England have advised that a 70% uptake rate is sufficient; nationally the coverage for children in 9 was 82% for the school based programme. School based providers (eg community trusts, social enterprise , community partnership etc) are commissioned to offer the vaccine in every school including private and faith schools which includes the initial offer and opportunities for those that may have missed this vaccinated at another time. principal of the Men ACWY and all public health programmes is to offer the intervention to 100% of the eligible population; the uptake of the vaccination remains the choice of the individual or families. The 20-30% of childrenl young adults not vaccinated in schools therefore fall into two groups: offered and declined not offered for a variety of reasons, eg programme error or incident as in this case, not attending school, home schooled, etc GP practices continue to be commissioned as part of a service to opportunistically offer the vaccine to anyone up to the age of 25_ This includes those who may have missed the opportunity to be immunised as part of the schools based programme: those attending university for the first time those aged 10 to 25 years who have not previously received dose of Meningococcal C containing vaccine. AIlI GP practices responsibility to ensure administrative processes are in place for service delivery. The process by which a GP practice offers the vaccine to all eligible children; involves working with the Child Health Information Services (CHIS) CHIS have a role to transfer information about public health interventions, transferring this to and school based services and GP practice , for those providers to act on and deliver their services to patients CHIS services and the 'failsafe' provide are improved as part of the NHS strategy for IT, improving the paperless flow of information across organisations by 2021_
2. The provision of the vaccination against Men ACWY appears to fall under an enhanced service for GPs As this is an optional addition to the GMS contract, is unclear whether all GP surgeries have a responsibility to capture unvaccinated children: You are correct that the provision of the Men ACWY vaccine for those who no longer fall within the schools based programme is the responsibility of the GP under an enhanced service . Whilst the enhanced service is optional, GPs have the responsibility of providing the Men ACWY vaccine for their registered eligible population and must inform NHS England commissioners as soon as possible if they are not taking up the enhanced service. NHS England will then ensure that those eligible patients are offered the service by an alternative primary care provider. Those eligible for immunisation remain eligible whether or not the practice accepts the service_ It does not appear that there is any form of audit to ensure that GP practices have in place systems to identify those children who are not captured by school programme and to in place measures to protect children, particularly before commencing university. High quality care for all, now and for future generations the Year being key have the from they being the put
The Child Health Information Service (CHIS) service is the organisation locally that records whether or not a childl young person has received a vaccine or other public health interventions, and acts to support the process of capturing information, including transferring information it receives from school based services to a GP practice, who then have the responsibility to act on the information received. Each has an established system in place to ensure that GP providers are made aware of vaccinations administered by school aged vaccination providers, with regular reports on the processed within CHIS coming to a national NHS England oversight group on a quarterly basis_ NHS England is working to ensure that all those eligible for vaccinations should be offered the vaccine either in school or by a GP practice Those who may have missed the opportunity to be vaccinated, remain eligible until they are 25 years f age_ Although the case of Lauren, is an unfortunate and avoidable death, Public Health England have advised that there has been decline in Meningococcal group W cases overall in England during 2017/18, and this decline is expected to continue to reduce across all ages including in unvaccinated adolescents and children: Thank you for bringing your concerns to the attention of NHS England: hope our response provides you with reassurance that NHS England are taking proactive steps to address your concerns
Sent To
- NHS England
- Public Health England
Response Status
Linked responses
1 of 3
56-Day Deadline
24 Aug 2018
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 03/10/2017, commenced an investigation into the death of Lauren Amelia Rose SANDELL. The investigation concluded at the end of the inquest on 2Sth June 2018. The conclusion of the inquest was a narrative conclusion: Lauren Sandell died as a result of meningococcal sepsis (serogroup W135). She fell within the cohort of patients requiring the MenACWY vaccination. Guidance available to the GP practice indicated that the vaccination should have been before the start of the new academic year. Her GP practice had signed up to an Enhanced Service Specification to provide the vaccination to patients of Lauren'$ age. This was signed between March to June 2016. The Enhanced Service Specification required an active call and re-call system to be in place for patients of Lauren'$ age. Lauren received no call or re-call from the practice. There was no alert placed on Lauren's notes to ensure that she was notified of the vaccination if and when she attended surgery: Practice Nurse raised the need for the vaccination opportunistically with Lauren'$ mother, on 13 September 2016 (5 days before Lauren left for university): The risks of not having the vaccination were not adequately explained to her mother: There was insufficient stock of the vaccine within the practice, for Lauren to be vaccinated prior to her departure to university: The Practice was not fully informed about the availability of the two different types of ACWY vaccination (one of which had an unrestricted supply): Had Lauren received the vaccination prior to attending university, it is that her death on 2 October 2016 would have been avoided.
Circumstances of the Death
Lauren Sandell turned 18 years old on the 23 January 2016. She should have received contact from her GP surgery to be vaccinated against the MenACWY vaccine prior to the beginning of the academic year (2016/7). The family first discovered the_need for the vaccine when it was mentioned opportunistically given The likely to her mother on the 13 September 2016 (5 days before she was leaving for University) The risks of Lauren not having the vaccine were not made clear to her. There were insufficient amounts of the vaccine within the surgery for Lauren to be vaccinated before leaving for university: An appointment was booked for the 28 October 2016. Lauren began to feel unwell on the 29 September 2016. She suffered from headaches/vomiting and aches and pains_ On the 2 October 2016 she became unresponsive at her home address and her life was pronounced extinct by paramedics on scene. (Further detail can be seen in the narrative conclusion):
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe that NHS London and ultimately NHS England have the power to take such action.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.