Child Death

Action Planned (AI summary) Norfolk and Suffolk NHS Foundation Trust has developed a process for joint working between teams for complex cases, implemented a risk assessment process for transfers, and is planning a multi-agency meeting to plan a learning event, following recommendations from a review. The Queen Elizabeth Hospital reports that a multi-disciplinary meeting has been held and a learning event is planned for February 2020, with the West Norfolk CCG taking the lead on organisation. Norfolk County Council commissioned a Serious Case Review with findings and recommendations and a learning event has taken place on 7th November 2019. A further event will take place in early February 2020. The CCG is organizing a multi-disciplinary learning event for NSFT, QEH, NCC, and EEAST staff to address concerns raised in the PFD, with an external facilitator identified and a date in mid-February 2020 planned. The event will include a pen portrait of the deceased, wishes from their parents, and messages from involved staff.

Action Planned (AI summary) The Department of Health and Social Care will review the care system, give local authorities a 4.4% real-terms increase in their Core Spending Power, and will be made available to all areas and CCGs, and through them to every school and college (including alternative provision settings) and children and young people's mental health services in England.

Action Planned (AI summary) The CAMHS team has commenced a review of the referral form, and a draft form was sent to the Clinical Director for Mental Health commissioning at Sheffield Clinical Commissioning Group (SCCG) for comments. The reviewed and updated form and guidance will be distributed to all General Practitioners by 12 July 2019.

Action Planned (AI summary) The MPS will review the roles and responsibilities of the police pursuits pod to ensure they are maximising information/intelligence opportunities. They will consider a mandatory checklist of indices at the start of a pursuit and ensure Pan London courses and refresher training include an input on information and intelligence gathering. This review will be completed by 31st October 2019.

Action Planned (AI summary) The London Ambulance Service raised the PFD regarding EpiPen usage with the UK Clinical Focus Group for IAED-MPDS and with the Executive Director of MPDS and awaits their conclusion. The Chief Medical Officer has shared the PFD with the Chair for The National Ambulance Service Medical Directors for their consideration. The Trust will review allergy action plans and injection techniques with children and carers in the clinic. They have added the additional process of posting or emailing each allergy plan to the school in question and advised the relevant department that before a clinic list is cancelled, the clinician is to review for time-critical appointments. Changes have been made so two adrenaline auto-injectors are kept with the child and two at school.

Action Planned (AI summary) NICE will reconsider the scope of their guideline on pancreatitis (NG104) when it is next reviewed, to consider lipase/amylase testing in young people. NHS Pathways reviewed the question regarding dark brown or black vomit and concluded removing 'coffee-grounds' could result in over-referral. As part of routine review and governance procedures, they are conducting a review of the gastrointestinal suite of pathways, with changes planned for Release 19 (deployed May 2020).

Action Planned (AI summary) The UK government published its Online Harms White Paper which sets out plans for legislation to make the UK the safest place in the world to be online, establishing a new statutory duty of care overseen by an independent regulator with powers to issue substantial fines. The government has convened a working group of social media and digital sector companies to explore what more they can do to help keep children safe online.

Action Planned (AI summary) Sheffield Children's and Sheffield Health and Social Care Trusts have jointly approved an addendum to the Transitions Policy, implemented a review process overseen by Associate/Directors for young people accessing care, and provided 'read only' access to electronic patient records for CAMHS activity to Sheffield Health and Social Care staff. The CCG approved a business case for a Home Intensive Treatment Team (HITT) on May 7th, 2019, with phased implementation planned from autumn 2019, and has begun recruiting nursing staff.

Action Planned (AI summary) Norfolk and Suffolk NHS Trust details actions planned including; instructing all clinical services to review their working practice in respect of record keeping and communication with partner agencies and a learning session to be delivered by the Head of Patient Safety and Safeguarding and the Legal Services Manager.