Child Death

Noted (AI summary) The Charity Commission acknowledges the report and states they are closely examining the concerns as part of their ongoing engagement with The Scout Association. They will be meeting with TSA again to discuss improvements and will take further regulatory action if needed. The Minister for Education and Welsh Language has noted the recommendations and passed them on to Welsh Government officials, noting that the UK Government is best placed to respond to the recommendation for a Public Inquiry into the Scout Association. The Children's Commissioner for Wales will seek updates from the Scouts Association and will share the PFD report with Estyn, who are expanding their inspections framework to include youth work. The Children's Commissioner will request updates from the Scouts Association by April 30th regarding actions to prevent future deaths/injuries. They have also called for Ofsted to play a larger role in assuring safety in youth work organisations. The Department for Education acknowledges the concerns raised, expresses condolences, and references existing guidance related to safeguarding and activity licensing but commits to no specific new actions. HSE will begin an investigation into Ben’s death and will also look at how they intervene generally with volunteering organisations that provide activities to young people such as the Scout Association to identify lessons for the future regulation of this sector. HSE will undertake a review to identify how this error occurred, and to ensure that it is not repeated and will be writing directly to Ben’s family to offer them an apology. Unity Insurance Services acknowledges receipt of the report and expresses sympathy, noting they are working with insurers and The Scout Association to support customers, and clarifying a factual inaccuracy regarding the chair in 2018. The Scouts Association details actions taken including updating POR (Policy, Organisation and Rules), developing new training modules ('Growing Roots'), creating a new safety committee, and updating risk assessment processes. They also describe planned reviews and consultations.

Noted (AI summary) Greater Manchester Integrated Care has delivered training sessions on ARFID and made all Stockport pediatricians aware of the recent Royal College of Child Psychiatrists published guidance in relation to ARFID. Information/learning has been shared across NHS Greater Manchester ICB. NICE has concluded that it is not best placed to develop guidance on avoidant/restrictive food intake disorder, and in particular in medical emergencies in eating disorders. They will refer the report to their surveillance team for consideration when the eating disorders guideline is next reviewed.

Noted (AI summary) The Department of Health and Social Care acknowledges the concerns raised and has forwarded them to NHS England, who are working with the Association of Ambulance Chief Executives (AACE) to review the concerns. AACE is consulting with expert advisors, obstetricians, midwives, and NHS England to review and update JRCALC guidance on maternal emergencies, including conveyance of patients when delivery is not progressing, with updates expected in approximately three months.

Noted (AI summary) NHS England acknowledges the concerns raised and explains the national context of radiologist shortages and the role of the GIRFT program and National Imaging Strategy. They highlight ongoing work to share learnings from PFD reports nationally. The ICB acknowledges the concerns and outlines actions being taken by the hospital trust. They state they are happy to continue working alongside acute colleagues to support a resilient safe model for patients. The trust is considering joint recruitment of a radiologist with a paediatric sub-specialism with another trust, a consultant is training in POCUS with a funding request for a machine, and they are reviewing collaboration with other hospitals. An action plan has been created to address the missed chest x-ray opportunity, and evidence has been submitted to complete the actions identified.

Noted (AI summary) NICE clarifies that it has not published a guideline on managing chickenpox, but it does publish a Clinical Knowledge Summary (CKS) on its website. They have shared the report with Agilio Software, the external company who develop the CKS. The Royal College of Paediatrics and Child Health (RCPCH) will share information and suggestions for local improvement from the coroner's report with its members via its patient safety portal. They are engaging with NHS England and the Patient Safety Commissioner on implementing Martha's Rule nationally and support the recommendation for a universal varicella vaccination programme.

Noted (AI summary) Mid and South Essex NHS Foundation Trust has shared learning with teams about the JRCALC protocol on managing severe asthma in children and is delivering training sessions focusing on the role of Adrenaline; they have also sent an email to staff regarding the use of Adrenaline in pre-hospital asthma resuscitation. The Ambulance Service has disseminated posters addressing human factors, developed a new training package on decision-making under pressure, and is providing regular updates on best practice for asthma management. They have removed the skill of intubation for general paramedics and are rolling out Advanced Paramedics in Critical Care cars across the region. They have also implemented the Patient Safety Improvement Response Framework. AACE will review the JRCALC asthma guideline and make changes if required, and will share the concerns with their national ambulance service medical directors’ group (NASMeD) to consider further education or awareness for clinicians regarding airway management and adrenaline administration. Essex Partnership University NHS Foundation Trust has implemented several changes in the Asthma & Allergy Children’s and Young Persons Service, including staff training, caseload reviews, translated care plans, smoking cessation courses, and links between universal services and the CAAS to improve education and training. Essex Partnership University NHS Foundation Trust has implemented several changes in the Asthma & Allergy Children’s and Young Persons Service, including staff training, caseload reviews, translated care plans, smoking cessation courses, and links between universal services and the CAAS to improve education and training. The Department acknowledges the concerns and describes the existing framework for healthcare professional training, including the National Capabilities Framework for Professionals who care for Children and Young People with Asthma. They note that employers are responsible for ensuring staff are trained to the required standards.

Noted (AI summary) NHS England is implementing improvements to the CYMPH inpatient pathway, aiming to reduce out-of-area placements and move towards community-based care; they are also developing a national admission protocol for children and young people with multi-agency partners. The Department of Health and Social Care acknowledges the concerns and notes NHS England's response and approach to reduce reliance on inpatient mental health beds, moving towards community-based care.