Parv Patel
PFD Report
All Responded
Ref: 2015-0457
All 1 response received
· Deadline: 24 Nov 2015
Coroner's Concerns (AI summary)
The report identifies that PEWS scores may not reflect current research into child illness, particularly in cases of sepsis, and may distract doctors from the fact that a child is seriously ill despite a low score.
View full coroner's concerns
_ That PEWS scores do not reflect current research into child illness day ,aged septic day having
Her Majesty's Coroner for the Northern District of Greater London (Harrow; Brent; Barnet; Haringey and Enfield) And that the Pews scores may tend to act to distract the doctors away from the fact that despite a low PEWS score a child might be seriously ill
Her Majesty's Coroner for the Northern District of Greater London (Harrow; Brent; Barnet; Haringey and Enfield) And that the Pews scores may tend to act to distract the doctors away from the fact that despite a low PEWS score a child might be seriously ill
Responses
Noted
The response acknowledges concerns about PEWS scores and describes ongoing national work by NHS England and the Royal College of Paediatrics and Child Health to develop a framework for recognising and responding to children at risk of deterioration. (AI summary)
The response acknowledges concerns about PEWS scores and describes ongoing national work by NHS England and the Royal College of Paediatrics and Child Health to develop a framework for recognising and responding to children at risk of deterioration. (AI summary)
View full response
Dear Mr Walker
Thank you for your letter to Jeremy Hunt about the death of Parv Patel. I am responding on his behalf as the Minister with responsibility for Child Health.
I was very sorry to hear of Parv’s death.
Your report gives an overview of the circumstances surrounding Parv’s admission to hospital and noted the following concerns;
• Paediatric early warning system (PEWS) scores do not reflect current research into child illness; and
• PEWS scores may tend to act to distract doctors away from the fact that, despite a low PEWS score a child may be seriously ill.
NHS England are continuing to work towards developing a consensus view on a paediatric early warning system. There is at present no nationally recommended PEWS score. The complexities of developing a single score are a challenge. It would have to reflect the differing needs and requirements of all children from infants to teenagers, with a range of greatly different underlying healthcare conditions. Developing such a score is the subject of current research funded by the National Institute for Health Research.
NHS England, with the Royal College of Paediatrics and Child Health (RCPCH), is now examining the elements of a framework for the recognition and response to children at risk of deterioration, which would be a PEWS system .This system would include such aspects as a structured communication, escalation to senior staff and review and would not remove the professional clinical view or indeed the parental or carers views or concerns. It should also consider the wider elements of clinical handover and briefings. It is recognised that a clinician could be distracted from identifying a child’s deterioration if only the score is considered in isolation from other factors.
I have sent your report on to Carol Ewing, Vice President of Health Policy at RCPCH: and to Peter Lachman, the Deputy Medical Director for Safety at Great Ormond St and clinical lead for the RCPCH-led Situation Awareness For Everyone project, to inform their work in this area.
I hope that this information is helpful and I thank you for bringing the circumstances of Parv’s very sad death to our attention.
Thank you for your letter to Jeremy Hunt about the death of Parv Patel. I am responding on his behalf as the Minister with responsibility for Child Health.
I was very sorry to hear of Parv’s death.
Your report gives an overview of the circumstances surrounding Parv’s admission to hospital and noted the following concerns;
• Paediatric early warning system (PEWS) scores do not reflect current research into child illness; and
• PEWS scores may tend to act to distract doctors away from the fact that, despite a low PEWS score a child may be seriously ill.
NHS England are continuing to work towards developing a consensus view on a paediatric early warning system. There is at present no nationally recommended PEWS score. The complexities of developing a single score are a challenge. It would have to reflect the differing needs and requirements of all children from infants to teenagers, with a range of greatly different underlying healthcare conditions. Developing such a score is the subject of current research funded by the National Institute for Health Research.
NHS England, with the Royal College of Paediatrics and Child Health (RCPCH), is now examining the elements of a framework for the recognition and response to children at risk of deterioration, which would be a PEWS system .This system would include such aspects as a structured communication, escalation to senior staff and review and would not remove the professional clinical view or indeed the parental or carers views or concerns. It should also consider the wider elements of clinical handover and briefings. It is recognised that a clinician could be distracted from identifying a child’s deterioration if only the score is considered in isolation from other factors.
I have sent your report on to Carol Ewing, Vice President of Health Policy at RCPCH: and to Peter Lachman, the Deputy Medical Director for Safety at Great Ormond St and clinical lead for the RCPCH-led Situation Awareness For Everyone project, to inform their work in this area.
I hope that this information is helpful and I thank you for bringing the circumstances of Parv’s very sad death to our attention.
Sent To
- Department of Health and Social Care
Response Status
Linked responses
1 of 1
56-Day Deadline
24 Nov 2015
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 the 19lh of November 2014 opened an investigation touching the death of Parv Patel 4 years old. The inquest concluded on the 14hh September 2015 The conclusion of the inquest was Narrative" , the medical case of death was 1a Influenza A infection
Circumstances of the Death
Parv Patel 4 years old; was taken to hospital on the 28th November 2014 suffering with an infection By 02.OOhrs the following morning he had become seriously unwell with symptoms of heart failure as a part of a picture, the fact that he was experiencing symptoms of heart failure at this time was not recognized until much later the following at 09.45 hrs. A doctor decided reasonably, to intubate Parv which; due to the development of a cardiac tamponade, precipitated his cardiac arrest and death at 13.2Shrs in the early afternoon Parv Patel died following intubation suffered a rare complication of flu:
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you [ANDIOR your organisation] have the power to take such action
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.