Marc Poole
PFD Report
All Responded
Ref: 2016-0045
All 1 response received
· Deadline: 28 Mar 2016
Coroner's Concerns (AI summary)
Multiple communication failures, poorly completed observation charts, lack of a paediatric sepsis protocol, and ineffective dissemination of medical updates contributed to systemic care failures.
View full coroner's concerns
_ _ (1) Poor communication on a number of levels Insufficient discussion with the parents regarding history, insufficient weight attached to the information they did provide at the time of admission and subsequently. Absence of any protocols of guidance as to how best to communicate with children with disabilities such as autism as MJ had. Communications between staff were poor, HCAs to nurses, nurses to doctors and between junior doctors and senior doctors. Ineffective communication of microbiology results which had been phoned through to the ward but not immediately passed on to those who needed to undertake assessment.
(2) PAWS The observation chart was poorly completed. There were occasions where incorrect scoring had been documented understating MJ's condition at that time. This was a form and source of information said to have been heavily relied upon but no clear protocols for doctors to regularly review and assess. It would seem further training is required to ensure accurate completion of this form and accurate scoring: (3) Sepsis in Paediatrics It is clear that consideration should be given to developing a protocol and guidance for those treating children: A paediatric screening tool needs to be provided. There needs to be clear explanations of the terms septic, sepsis, septic shock, septicaemia, bacteraemia. These terms were used interchangeably. It needs to be made clear to staff the signs they should be looking out for and how these might be responded to_ (4) Dissemination of kex information and medical updates There needs to be a review of the systems currently in place for disseminating such information. was not reassured from the evidence heard that the current system is effective in that regard or understood by staff at the trust.
(5) Poor_record keeping Even when a ward is busy, it is imperative that clear records are made of significant events or developments There were a number of occasions where no record was made at all Coroner'$ Court and Office, Doncaster Court; College Road, Doncaster; DNI 3HS Tel 01302 737135 Fax 01302 736365 fully Crow n
(2) PAWS The observation chart was poorly completed. There were occasions where incorrect scoring had been documented understating MJ's condition at that time. This was a form and source of information said to have been heavily relied upon but no clear protocols for doctors to regularly review and assess. It would seem further training is required to ensure accurate completion of this form and accurate scoring: (3) Sepsis in Paediatrics It is clear that consideration should be given to developing a protocol and guidance for those treating children: A paediatric screening tool needs to be provided. There needs to be clear explanations of the terms septic, sepsis, septic shock, septicaemia, bacteraemia. These terms were used interchangeably. It needs to be made clear to staff the signs they should be looking out for and how these might be responded to_ (4) Dissemination of kex information and medical updates There needs to be a review of the systems currently in place for disseminating such information. was not reassured from the evidence heard that the current system is effective in that regard or understood by staff at the trust.
(5) Poor_record keeping Even when a ward is busy, it is imperative that clear records are made of significant events or developments There were a number of occasions where no record was made at all Coroner'$ Court and Office, Doncaster Court; College Road, Doncaster; DNI 3HS Tel 01302 737135 Fax 01302 736365 fully Crow n
Responses
Action Taken
The Trust reviewed the Paediatric IPOC to ensure better communication with parents about a child's clinical history, particularly for children with disabilities. They also revised the Sepsis Recognition and Management Pathway for children, including training for staff and updated equipment, and implemented a 'Red Flag Sepsis' poster for use by all staff. (AI summary)
The Trust reviewed the Paediatric IPOC to ensure better communication with parents about a child's clinical history, particularly for children with disabilities. They also revised the Sepsis Recognition and Management Pathway for children, including training for staff and updated equipment, and implemented a 'Red Flag Sepsis' poster for use by all staff. (AI summary)
View full response
Dear Ms Mundy RE: Marc Jason Stephen Poole (Deceased) D.O.B: 29 September 2008 D.O.D: 18 2015 Thank you for your letter of 8 February 2016 addressed to Mr Mike Pinkerton, Chief Executive, Doncaster & Bassetlaw NHS Foundation Trust. With respect to the concluded inquest on Marc Jason Stephen Poole the Regulation 28 report dated 2 February 2016, highlighted a number of concerns and would wish to take the opportunity to address these in the order that they have been listed. have been assisted in the course of this by Matron Andrea Bliss and Mr Eki Emovon, Clinical Director, Children and Family Care Group. Rclis May
1. Poor communication on a number of levels With respect to the discussion with the parents regarding a child' s clinical history, in order to ensure better communication the team have reviewed the Paediatric IPOC. Staff have been made aware of the need to listen to parents and take their views into consideration when assessing the clinical picture in any child who is admitted. Should children suffer from disabilities, medical and nursing staff will record, under the respective part of the Paediatric IPOC, how such children are communicated with and whether their disability further impedes their ability to communicate with strangers and hence the need to have more detailed and in depth conversations with parents. This situation will continue to pertain throughout the child's stay in hospital: With respect to ineffective communication of microbiology results, the team has considered the issue of outstanding test results and confirmed that during clinical handovers the results should be accessed through ICE: outstanding matters will form part of the documentation in the handover process in order to confirm that they are followed up and acted upon. In respect of receipt of urgent blood results from the laboratory via telephone, staff have been made aware that it is the responsibility of the individual taking the call to record the results on the IPOC and to verbally share the results with the medical staff as well as date, time and sign the entry and record the member of medical staff that the results have been shared with. 2 PAWS (Paediatric Advanced Warning Score) Staff have been made aware that at the inquest it was highlighted there were a number of poorly completed charts with incomplete scores during the episode of care: It was the case that temperature readings had been recorded without a corresponding record of the heart rate and respiratory rate being undertaken at the same time which will enable significance to be attached to the result and correctly identify scores: additional training needs for staff have been noted and are in process of being addressed. It is to be noted that all paediatric warning scores within the region are reviewed as part of the network of the Paediatric Operation and Delivery Network led by the Network Clinical Educator and the team will ensure that any developments with respect to PAWS will be filtered down to front line staff in order to continue to maintain and accurate marker of the condition of a sick child.
3. Sepsis in Paediatrics The inquest noted that there was lack of use of the sepsis tool kit and this is of significant concern both to your office as well as the Trust. Since the outcome of the inquest the Trust has worked rapidly to introduce such a tool based on the UK Sepsis Trust tool to which there has been both nursing and medical contribution: attach the tool which has been agreed, implemented and disseminated in all the clinical Any Any being
areas: Multi-disciplinary staff development will continue to provide training on sepsis in children and unexpected deterioration in children. This training will include medical staff on induction for each house_
4. Dissemination of key information and medical updates The Trust has reviewed its systems for disseminating such information: The Sepsis tool kit was disseminated and implemented for adults but for some reason this was not achieved in paediatrics The revised process involves such information being received by the Patient Safety Review Group (PSRG) and then disseminated through members of the group to the relevant areas where the information or update is relevant: The PSRG will monitor that guidance has been implemented. The Trust Sepsis Lead has undertaken to support the Paediatric team with monitoring of the implementation of the Sepsis tool. 5 Poor record keeping It is acknowledged that record keeping was poor both from medical and nursing staff and | confirm the individuals who were involved in this case have reflected on this and the importance of recording care that is given to patients_ Staff have been reminded that record keeping is in line with what is expected by the Nursing and Midwifery Council and the General Medical Council Guidelines on record keeping: In respect of this all Consultants within the Trust are required to undertake an audit of clinical records as part of their yearly appraisal. You would be interested to note that there have been the following immediate changes to practice:
1. In all instances the minimum recording on PAWS includes temperature measurement; pulse and heart rate measurement as well as frequency of respirations. This is documented together with the child'$ colour at the time that such observations have been undertaken. skin change such and pallor, mottling or rash is documented on the PAWS chart and a minimum temperature pulse and respiratory rate performed at that particular point in time_ 3_ The PAWS score is documented for each individual observation and then totalled. observations will be documented directly onto the PAWS chart: Staff have been made aware of these changes in practice and have been required to complete a self-declaration form. This allows opportunity for individuals to inform the Line Manager if require additional training relating to observations and PAWS. Each Healthcare Assistant is also asked to complete a self-declaration form indicating that they were competent to undertake and document physiological observations and to report to a Registered Nurse any observations/PAWS outside of normal parameters. Each Registered Nurse has been asked to complete a self- good Any Any they
declaration to indicate that were competent to undertake document and interpret physiological observations and able to report to medical staff any observations/PAWS outside of normal parameters trust that this will provide assurance that appropriate action has been taken following the death of Marc Jason Stephen Poole: The changes will continue to be monitored by the Care Group Clinical Governance team and Patient Safety Review Group May take this opportunity to invite you to revert back to me should you feel it necessary to do so_ Yoursisincerely Deputy Medical Director Clinical Standards es they
Doncaster and WS Paediatric Sepsis Screening and Action Tool Bassetlaw Hospitals NAS Foundation Trust Sepsis is a time critical condition. Screening, early intervention and immediate treatment save lives. This tool should be applied to all children with suspected infection or who have observations outside normal limits_ 1 , Could this be an infection? Sepsis not present now: Observe and review as per clinical need. For example: Pneumonia Urinary Tract Infection Abdominal pain or distension Sepsis considered Inform responsible clinician. Meningitis Begin hourly observations_ Cellulitis/ septic arthritis/ infected wound Reassess for severe sepsis hourly Ensure FBC , CRP U&E, LFT BM; venous blood gas with lactate & blood cultures sent; 2 Are any 2 Systemic inflammatory response Monitor urine output: syndrome (SIRS) criteria present Temperature
38.50C or < 360C Inappropriate tachycardia or bradycardia When to consider observations Altered mental status (including sleeping/ abnormal: irritability/ lethargyl floppiness Tachycardia Bradycardia Hypotension systolic BP Reduced peripheral perfusion/ prolonged days [0 week 180 00 <65 capillary refilll reduced urine output or wet nappies week t0 morth >180 <i00 <75 month [0 year 180 <90 100 2-5 years >140 NA <94
3. Is any one Red present? 6-|2yrs >130 NA 105 Hypotension 13 t0 18 years >0 NA Blood gas lactate > 4 mmoll Capillary refill > 5 seconds Palel mottled/ ashen/ blue or non-blanching Red Sepsis rash This is a time critical condition Oxygen needed to maintain saturations >92% Take bloods as mentioned in the box Respiratory rate 60 min-1 or > 5 below the Sepsis considered. Assume severe normal, or grunting sepsis present: AVPU = V,P or U Paediatric Sepsis Six: Parents report one of: High-flow oxygen. excessively dry nappies, lack of response to 2 Take cultures. glucose, FBC , lactate, CRP social cues, significantly decreased activity, or 3 Intravenous or intraosseous antibiotics weak; high-pitched or continuous cry 4 Fluid resuscitation (2Omllkg) 5 Involve senior clinicians early 6 Consider inotropic support early THEUK This tool is developed original work of the UK Sepsis Trust: The Paediatric Record the time each of these actions iS SEPSIS Sepsis Six Paediatric Red Flag Sepsis completed. All actions should be completed are the intellectual property of the UK TRUST Sepsis Trust as soon as possible but always within 60 minutes Flag Flag fromn and
1. Poor communication on a number of levels With respect to the discussion with the parents regarding a child' s clinical history, in order to ensure better communication the team have reviewed the Paediatric IPOC. Staff have been made aware of the need to listen to parents and take their views into consideration when assessing the clinical picture in any child who is admitted. Should children suffer from disabilities, medical and nursing staff will record, under the respective part of the Paediatric IPOC, how such children are communicated with and whether their disability further impedes their ability to communicate with strangers and hence the need to have more detailed and in depth conversations with parents. This situation will continue to pertain throughout the child's stay in hospital: With respect to ineffective communication of microbiology results, the team has considered the issue of outstanding test results and confirmed that during clinical handovers the results should be accessed through ICE: outstanding matters will form part of the documentation in the handover process in order to confirm that they are followed up and acted upon. In respect of receipt of urgent blood results from the laboratory via telephone, staff have been made aware that it is the responsibility of the individual taking the call to record the results on the IPOC and to verbally share the results with the medical staff as well as date, time and sign the entry and record the member of medical staff that the results have been shared with. 2 PAWS (Paediatric Advanced Warning Score) Staff have been made aware that at the inquest it was highlighted there were a number of poorly completed charts with incomplete scores during the episode of care: It was the case that temperature readings had been recorded without a corresponding record of the heart rate and respiratory rate being undertaken at the same time which will enable significance to be attached to the result and correctly identify scores: additional training needs for staff have been noted and are in process of being addressed. It is to be noted that all paediatric warning scores within the region are reviewed as part of the network of the Paediatric Operation and Delivery Network led by the Network Clinical Educator and the team will ensure that any developments with respect to PAWS will be filtered down to front line staff in order to continue to maintain and accurate marker of the condition of a sick child.
3. Sepsis in Paediatrics The inquest noted that there was lack of use of the sepsis tool kit and this is of significant concern both to your office as well as the Trust. Since the outcome of the inquest the Trust has worked rapidly to introduce such a tool based on the UK Sepsis Trust tool to which there has been both nursing and medical contribution: attach the tool which has been agreed, implemented and disseminated in all the clinical Any Any being
areas: Multi-disciplinary staff development will continue to provide training on sepsis in children and unexpected deterioration in children. This training will include medical staff on induction for each house_
4. Dissemination of key information and medical updates The Trust has reviewed its systems for disseminating such information: The Sepsis tool kit was disseminated and implemented for adults but for some reason this was not achieved in paediatrics The revised process involves such information being received by the Patient Safety Review Group (PSRG) and then disseminated through members of the group to the relevant areas where the information or update is relevant: The PSRG will monitor that guidance has been implemented. The Trust Sepsis Lead has undertaken to support the Paediatric team with monitoring of the implementation of the Sepsis tool. 5 Poor record keeping It is acknowledged that record keeping was poor both from medical and nursing staff and | confirm the individuals who were involved in this case have reflected on this and the importance of recording care that is given to patients_ Staff have been reminded that record keeping is in line with what is expected by the Nursing and Midwifery Council and the General Medical Council Guidelines on record keeping: In respect of this all Consultants within the Trust are required to undertake an audit of clinical records as part of their yearly appraisal. You would be interested to note that there have been the following immediate changes to practice:
1. In all instances the minimum recording on PAWS includes temperature measurement; pulse and heart rate measurement as well as frequency of respirations. This is documented together with the child'$ colour at the time that such observations have been undertaken. skin change such and pallor, mottling or rash is documented on the PAWS chart and a minimum temperature pulse and respiratory rate performed at that particular point in time_ 3_ The PAWS score is documented for each individual observation and then totalled. observations will be documented directly onto the PAWS chart: Staff have been made aware of these changes in practice and have been required to complete a self-declaration form. This allows opportunity for individuals to inform the Line Manager if require additional training relating to observations and PAWS. Each Healthcare Assistant is also asked to complete a self-declaration form indicating that they were competent to undertake and document physiological observations and to report to a Registered Nurse any observations/PAWS outside of normal parameters. Each Registered Nurse has been asked to complete a self- good Any Any they
declaration to indicate that were competent to undertake document and interpret physiological observations and able to report to medical staff any observations/PAWS outside of normal parameters trust that this will provide assurance that appropriate action has been taken following the death of Marc Jason Stephen Poole: The changes will continue to be monitored by the Care Group Clinical Governance team and Patient Safety Review Group May take this opportunity to invite you to revert back to me should you feel it necessary to do so_ Yoursisincerely Deputy Medical Director Clinical Standards es they
Doncaster and WS Paediatric Sepsis Screening and Action Tool Bassetlaw Hospitals NAS Foundation Trust Sepsis is a time critical condition. Screening, early intervention and immediate treatment save lives. This tool should be applied to all children with suspected infection or who have observations outside normal limits_ 1 , Could this be an infection? Sepsis not present now: Observe and review as per clinical need. For example: Pneumonia Urinary Tract Infection Abdominal pain or distension Sepsis considered Inform responsible clinician. Meningitis Begin hourly observations_ Cellulitis/ septic arthritis/ infected wound Reassess for severe sepsis hourly Ensure FBC , CRP U&E, LFT BM; venous blood gas with lactate & blood cultures sent; 2 Are any 2 Systemic inflammatory response Monitor urine output: syndrome (SIRS) criteria present Temperature
38.50C or < 360C Inappropriate tachycardia or bradycardia When to consider observations Altered mental status (including sleeping/ abnormal: irritability/ lethargyl floppiness Tachycardia Bradycardia Hypotension systolic BP Reduced peripheral perfusion/ prolonged days [0 week 180 00 <65 capillary refilll reduced urine output or wet nappies week t0 morth >180 <i00 <75 month [0 year 180 <90 100 2-5 years >140 NA <94
3. Is any one Red present? 6-|2yrs >130 NA 105 Hypotension 13 t0 18 years >0 NA Blood gas lactate > 4 mmoll Capillary refill > 5 seconds Palel mottled/ ashen/ blue or non-blanching Red Sepsis rash This is a time critical condition Oxygen needed to maintain saturations >92% Take bloods as mentioned in the box Respiratory rate 60 min-1 or > 5 below the Sepsis considered. Assume severe normal, or grunting sepsis present: AVPU = V,P or U Paediatric Sepsis Six: Parents report one of: High-flow oxygen. excessively dry nappies, lack of response to 2 Take cultures. glucose, FBC , lactate, CRP social cues, significantly decreased activity, or 3 Intravenous or intraosseous antibiotics weak; high-pitched or continuous cry 4 Fluid resuscitation (2Omllkg) 5 Involve senior clinicians early 6 Consider inotropic support early THEUK This tool is developed original work of the UK Sepsis Trust: The Paediatric Record the time each of these actions iS SEPSIS Sepsis Six Paediatric Red Flag Sepsis completed. All actions should be completed are the intellectual property of the UK TRUST Sepsis Trust as soon as possible but always within 60 minutes Flag Flag fromn and
Sent To
- Doncaster and Bassetlaw NHS Foundation Trust
Response Status
Linked responses
1 of 1
56-Day Deadline
28 Mar 2016
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 22/05/2015 commenced an investigation into the death of Jason Stephen Poole, age 6. The investigation concluded at the end of the inquest on 1st February 2016. The conclusion of the inquest was a Narrative conclusion: Marc Jason Stephen Poole was admitted to the Doncaster Royal Infirmary on 16 2015 with a suspicion of infection with no focus Prolonged assessment and investigations delayed provision of antibiotic therapy Had antibiotics been commenced on 16 May 2015 it is likely that MJ would have survived. He died in Sheffield Children's Hospital on 18 2015 from effects of pneumococcal septicaemia The cause of death was Septicaemic shock due to pneumococcal septicaemia due to Sinusitis
Circumstances of the Death
Mark Jason Stephen Poole (MJ) was admitted to the Doncaster Royal Infirmary on the 16th 2015 having being unwell all complaining of a headache, vomiting and unable to walk: He was admitted to hospital where infection was suspected and investigations commenced. A decision was made not to commence antibiotics on admission on 16 to allow investigations to take place_ Whilst bloods have been taken on admission, there was no clear direction that they should have been and indeed these were taken in the early hours of the following morning: Antibiotics were not commenced at that time as there was a wish to undertake a chest X ray and urine sampling in an effort to first find a focus of infection. Antibiotics were to be commenced after those steps had been undertaken: Following completion of initial investigations at around 16.40 on the 17th May, antibiotics were commenced. During the course of this afternoon MJ remained unwell The clinical evidence was that MJ's observations were stable save for the odd spike in temperature. The family's evidence was that MJ remained unwell: The observation chart was not completed as it should have been and calculation of warning scores were inaccurate on more than one occasion. As it was, antibiotics were commenced at 16.40 on 17/h May after a urine sample had been taken and tested for. MJ also developed mottling on his lower limbs which faded but returned. There was insufficient communication regarding the appearance and nature of the rash: There was delay in the elevated CRP level for bloods taken that afternoon being communicated to the treating doctors and acted upon.
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you; Mr Mike Pinkerton, The Chief Executive has the power to take such action
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.