Child Death

Action Planned (AI summary) North East London Foundation Trust is working with the Kent and Medway ICS and the local authority to learn lessons from the report, and has put training in place for all relevant staff on the signs and impacts of the relevant condition, and introduced reviews for high complexity cases. Training on Prader-Willi syndrome has been provided to CYPMHS staff at NELFT, and joint posts have been created across the Local Authority and Primary Care to identify children with additional needs early. Kent has also mobilised the National NHS England Designated Key Worker Early Adopter programme and continues to develop programmes for early intervention and support. The Department for Education is working with the Children’s Commissioner’s Office and the Information Commissioner’s Office (ICO) to identify ways to better improve data sharing in child safeguarding cases. They have also committed to publishing an ambitious implementation strategy later this year.

Action Planned (AI summary) The council made Autism awareness training mandatory for all staff working directly with children and young people, to be completed by 31 March 2022. It noted the Coroner's concern regarding post-death reviews, stating that SCC follows national guidance and took appropriate steps by way of a Thematic Review which was accepted by the National Panel. The CCG details actions taken including a Surrey CDR team meeting, incorporating thematic review learning into Surrey Children Services academy training, establishing a multi-agency task and finish group and a children and young person subgroup of the Surrey Suicide Prevention Partnership. Oskar's death will be presented at the next suicide themed CDOP meeting and learning shared nationally via NCMD. The Department for Education is conducting reviews of special educational needs and disability and of the children’s social care system, which will lead to significant reform of the support available for the most vulnerable of children and young people. The Child Safeguarding Practice Review Panel are developing a framework for undertaking rapid reviews, developing a quality assurance framework and publishing anonymised examples of good quality rapid reviews as exemplars of good practice.

Action Planned (AI summary) NICE acknowledges the guideline on gastroenteritis in under 5s [CG84] does not align with the UK Resuscitation Council’s 2021 guideline on paediatric advanced life support, and has forwarded the report to their guideline surveillance team who will review the UK Resuscitation Council’s 2021 guideline and consider if CG84 and other related NICE guidance need to be updated.

Action Planned (AI summary) NHS England is working with ELFT to strengthen knowledge and understanding of transitions issues in each other’s areas and a shared transition protocol or protocols that link together. They are committed to improving the availability of inpatient mental health support and alternatives to admission for Children and Young People. The Trust has reinforced transition protocols, reviewed the serious incident report into Mr Wilden’s death and the Trust’s transition policy and protocols with relevant staff members. An administrator pulls a list of all existing service users on a monthly basis to address the transitions policy.

Action Planned (AI summary) EMAS will be sharing updated guidance, national PGD and learning from this PFD across the Ambulance Pharmacists Network. Updated guidance and training package is being developed and will be rolled out during 2022/23 which will include the option for clinicians to administer buccal midazolam to adults (18 years and over) who present with convulsive status epilepticus when it is not available within the home as a prescribed medication.

Action Planned (AI summary) DHSC notes that £52 million was announced to fast track the provision of online maternity records and NHSE has updated the maternity early warning score (NEWS2) chart and the updated element seeks to focus more attention on pregnancies at high-risk of fetal growth restriction. A standardised risk assessment tool that all trust should use at the onset of labour has been developed.