Dear Mr Pollard Mikey James Hornby (Deceased) Response to Regulation 28: Report to Prevent Future Deaths to Bridgewater Community Healthcare NHS Foundation Trust Please find below the response of Bridgewater Community Healthcare NHS Foundation Trust following the inquest into the death of James Hornby and the Regulation 28 Report which you issued on 15 December 2014_ Your concerns were set out in the Regulation 28 Report as follows: "During the course of the inquest the evidence revealed matters giving rise to concern; In opinion there is a risk that future deaths wili occur unless action is taker (nche cicurestancesy is my statutory to report to you The MATTERS OF CONCERN are as follows:- On the first attendance at the Out of Hours Service, the attending staff having seen the infected umbilical cord, did not immediately send to the Hospital (as would have been the correct procedure according to the Consultant Lead Paediatrician who gave evidence to me)_ Chief Executive: Dr Kate Fallon Chairman: Holden Headquarters: Bevan House, 17 Beecham Court; Smithy Brook Road, Wigan;, WN3 6PR Mikey duty Mikey Harry

On the second attendance the doctor failed to appreciate the seriousness of the situation and at 10.45 at night sent the child home with & prescription for analgesia (which could not be filled until the following in event) . The Consultant Paediatrician gave evidence to me "that there was a high probability that he would have survived" had he been sent to the hospital at this time as he could and would have been administered an intra- venous anti-biotic_ If there is any realistic possibility of condition meningitis , the child should have been immediately admitted to the hospital. The GP covering the surgery that night indicated that they do not have the facility to take a simple blood test: If this is the case, then should utilise the adjacent facilities at the Emergency Department of the hospital. You also indicated that in your opinion, "there is clear training need identified here, in relation to the appreciation of this type of occurrence with very young children". Response of Bridgewater Community Healthcare NHS Foundation Trust Procedures for referral from out of hours to Hospital In 2013, the Trust implemented national NICE guidance dated May 2013 entitled "Feverish illness in children: Assessment and initial management in children younger than 5 years which is based on validated algorithms_ A copy of a link to the NICE guidance is enclosed, for your ease of reference: http:IIwww nice org.uklguidancelcg16Olchapterlrecommendations The Trust is fully compliant with this guideline The Trust uses the Paediatric Early Warning Score (PEWS) system in the GP Out of Hours service as way of ensuring that the steps recommended in the NICE guidance are considered (please see attachment one). Although the score sheet was not available during examination of Baby Mikey, running the score from the clinical data of the consultation score is 0-2 which did not indicate further action was required. If either or had decided that further action was required, there is a well-defined pathway for referral of patients to the Paediatricians at the hospital. The Trust reviewed the care provided to baby Mikey through its Root Cause Analysis process, which concluded in May 2014 This included review by peers within the organisation. The root cause analysis investigation concluded that complied with NICE guidance in his assessment 0f baby Mikey but that more attention could have been given to his feeding pattern and the possibility of dehydration. Appropriate safety netting advice was also provided. The Root Cause Analysis undertaken by the Trust did identify areas of learning, namely: Ensuring a full history is taken the parents when assessing babies, in particular in relation patterns . 2 Ensuring that documentation (the PEWS sheet) is available to practitioners on the electronic system. 3 Ensuring that information can be shared between organisations easily and quickly: day any very the being they very the from feeding

Blood tests within the out of hours service In common with any GP practice, the GP Out of Hours service does not routinely take blood children, including urgent circumstances; as we would not receive report back in timely enough manner to influence our decision making If a practitioner felt that a blood test was likely to be important to clinical decision making process, there is a clear referral protocol to the Paediatric department. A&E is not a referral route that we would use as there are pathways for an emergency referral to be made directlv_to the Paediatricians rather than patients waiting unnecessarily in A&E At the time saw the patient; blood test was not deemed necessary; as evidenced through the NICE guidelines but if it had have been, an emergency referral to the Paediatricians would have been made_ Although it is unlikely to have affected the outcome in this tragic case, we have internally reflected that the Out of Hours cupboard stock of paracetamol should have been used rather than issuing a prescription at that time of night, particularly in the light of the age of the baby. This has been communicated to practitioners within the service, and we are sorry that it did not occur in this case
3. Training All new staff undertake both a corporate and a local induction to ensure are aware of the policies and procedures in place as take up post, new Or reviewed Policies, Procedures and Guidelines are cascaded to clinical and medical staff with advice on the areas that need to be supported in practice via bulletin to staff (examples included please see attachments two and three): Significant guidance such as the new NICE advice on feverish illness in children is implemented into practice with templates to support assessment and management of care. Ongoing checks on the quality of the services we provide are made via quarterly clinical audit reviews, where a sample of clinical and medical records from each practitioner are reviewed by the clinical director enabling best practice to be recognised and shared with colleagues Where best practice is not followed period of supervision and formal support with competency improvement action plans is implemented. Annual appraisals take place with all staff. Learning from incidents in service allows GPs to review their training needs so that alongside maintaining their annual Mandatory and Statutory Training, particular development needs can be met. For GPs in the Out of Hours Service, their Bridgewater-specific training will often run alonaside continuing professional development undertake as part of their practice. In case, he has undertaken training on management of the severely ill child to support his general practice role You may be aware that the Warrington Safeguarding Children Board is undertaking a local review of the case and will share a copy of your Regulation 28 report with the reviewers_ If you would wish to be kept informed of the outcome of the review, please do let me know: hope that this responseprovides assurance that the policies and practices implemented by Bridgewater Community Healthcare NHS Foundation Trust are in with national guidelines issued by NICE_ The Trust reacted very swiftly to the extremely sad news of Mikey's death: We would like to extend our sincere condolences to his family and have met with them as part of the Trust's complaints process We would of course be happy to meet again if the family would find that helpful. from the drug they they Any sthe they line

Please do not hesitate to contact me if you require ay further information in relation to our response.