Dear Mr Hinchliff INQUEST TOUCHING THE DEATH OF CONNOR ADRIAN TURNER (Deceased) refer to your correspondence of 6th March 2015, received 1Oth March, regarding the inquest touching the death of Connor Adrian Turner and the Regulation 28 Report to Prevent Future Deaths in respect of this case_ We have considered the contents carefully and the responses to the matters of concern you have raised in the report are detailed below. In your report you highlight that There is no system in place for nursing staff to instruct and train parents and carers in the transfer of the oxygen supply from the main supply to the portable oxygen cylinder: (2) That parents and carers should be initially supervised in performing this task until are deemed to be competent to do so. (3) That when a transfer has been made in preparation for the patient leaving the hospital, albeit temporarily, the patient should not be allowed to leave until an independent check has been made and all concerned are satisfied that the apparatus is functioning correctly and that those the patient of hospital are competent to use the apparatus and that the appropriate reference to this should be made in the case notes will recall that; following Connor's 3ad death, the Trust undertook & serious incident investigation with a View to identifying how the safety and quality of our systems and processes could be improved and to ensure the learning was shared. Page 1 of 3 very they taking out You

The contents of the report were considered in evidence at the inquest was reassured to note that the Trust's investigation report included a number of recommendations which echoed The recommendations contained in your subsequent Regulation 28 report_ The Trust's independent investigator recommended that: Records of training and competence for basic life support and oxygen therapy for parents and staff should be completed and signed by parents and staff; A formal risk assessment for patients who have not yet been home with oxygen should be completed by the consultant in charge of the patient's care_ The risk assessment should be used with a checklist to: Confirm that the appropriate training of parents has occurred; Confirm that a record of this is documented; Confirm that the parents are aware of their responsibility for the patient's safety while off the ward (in writing and signed by the parents); State the length of time that the patient can be absent from the ward (making it clear what time the patient must be returned from the ward) Prompts to revisit this initial risk assessment should exist and be triggered when there is a change in condition , diagnosis or when an incident occurs either on or off the ward Staff should document where parents intend to take the patient before leave for any trip, and ensure the planned timeframe is within that permitted by the Consultant A check to ensure that the oxygen cylinder is running correctly should be made before the family leave the ward with the patient_ Evidence was given at the inquest of the actions that have been implemented following the publication of the investigation report: In summary; the clinical team has devised and implemented three documents which are completed by staff and parents. These are: (a) A risk assessment for parent supervised trips otf the ward tor children requiring supplemental oxygen; this assessment tool is designed to act as a prompt to ensure all appropriate checks, training; education and documentation is completed for a child who is dependent on supplemental oxygen to be safely taken off the ward by their parents The first part of this form is completed prior to the first trip away from the ward by each parent intending to supervise the trip and the consultant responsible for the child on the day of the trip_ A copy of the form is given to the parentls and copy is filed in the child's notes_ The second part of the form is completed prior to each subsequent trip away the ward. (b) A checklist for patients leaving a ward area who require oxygen therapy; this contains a number of clinical safety prompts including confirmation that the Sa02 has stayed above an agreed level for 48 hours without an increase of oxygen and if the oxygen requirement has increased in that period the child should not be allowed off the ward; a check to ensure that the cylinder valve is turned to "open' and free flowing oxygen can be felt when the cylinder is turned on; that parents can demonstrate how to turn cylinder on and off; parents can demonstrate how to set cylinder flow rate; a record is made of how long the cylinder will last and confirmation that the parents are aware of confirmation that the saturation monitor is fully charged.

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(c) A risk assessment for delivery of oxygen therapy that staff complete with parents_ This includes issues such as the risk of fire or burns from smoking; restriction of oxygen supply if tubing is kinked or trapped; risk of alcohol gels and oil based emollients; and risks of unauthorised adjustment of flow rate on oxygen equipment: As part of this process parents are educated and instructed on the reason for the oxygen; the prescribed flow rate and hours of use; to operate the equipment safely. have attached copies of the documents for your information Thank you for bringing these matters to my attention. do hope that this response has assured you that the Trust has given careful consideration to the matters of concern you have raised and had already taken action to address these If | can be of any further assistance please do not hesitate to contact me Kind regards