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Serious case review

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3.6 North West Ambulance Service (NWAS)
3.6.1 NWAS provides emergency and non-emergency pre-hospital medical care to all patients throughout the North West Region. It also provides patient transport services for those patients unable to travel independently to and from hospital.
3.6.2 The IMR has been prepared by the Safeguarding Practice Manager and countersigned by the Head of Clinical Safety. The report is written using the electronic records from the Sequence of Events (SOE) of the Emergency Service Control and Command System and the clinical record completed by the attending crew with details of the incident, patient observations, clinical interventions and treatment. The three staff who attended the emergency call were interviewed by the police and the records of these have contributed to the IMR.
3.6.3 NWAS has maintained two separate databases of vulnerable children and adults since 2006. There had been no referrals for any adult or child from Address 1.
3.6.4 An emergency call made by a passer-by was received (this was about seventy minutes after the appointment, in paragraph 3.4.7 above at the GP practice). The address was logged and the patient identified as a child of a few months who was in the mother’s arms but not breathing or conscious. The call was coded as ‘urgent’ using standard government codings and initially a single crew Rapid Response vehicle was allocated. The coding was then upgraded to ‘priority’ and a two person ambulance allocated. A different Rapid Response vehicle with a paramedic who had paediatric training and a different ambulance with two staff became available closer to Address 1.
3.6.5 The vehicles arrived at the address. The Rapid Response paramedic found Child 1 inside Address 4 receiving cardio-pulmonary resuscitation from the male caller. He picked up the baby and proceeded to the ambulance and, with the ambulance senior paramedic, continued to provide treatment using a bag valve mask and then a defibrillator.
3.6.6 Initially Adult 1 was in the ambulance with Child 2, but she took Child 2 back into the house, and was taken back to the ambulance by the Emergency Medical Technician to travel to the hospital.
3.6.7 The ambulance crew alerted the hospital of the nature of the emergency, arriving at Hospital 1 shortly after.
3.6.8 During the journey the Emergency Medical Technician asked Adult 1 what had happened. The conversation was difficult because of Adult 1’s limited English at that time, but by asking ‘yes/no’ questions and with gestures, a picture of events was described, of the visit to the GP, and Adult 1 coming downstairs and seeing that Child 1 ‘wasn’t right’.
3.6.9 At the hospital the technician stayed with Adult 1 until a nurse came to take over her care.
3.6.10 The IMR notes that the service met all expected practice standards, notifying NWAS Support Centre of a possible Sudden Untoward Death of a Child. The exception was that the records show that the Emergency Control Centre did not notify the police.
3.6.11 The IMR makes two recommendations. The first is to remind all staff that Language Line is available as an emergency service to ensure crucial information can be noted prior to arrival at hospital; the second is to ensure the review of Sudden Untoward Death of Children procedures are urgently updated to stress the need to notify the police when the service takes a child to hospital when there is an Acute Life Threatening Event or a Sudden Untoward Death. The failure to report to the police has been noted in a previous SCR by NWAS. The importance has to be stressed as it prevents contamination of a possible crime scene.
3.7 North West and North Wales Paediatric Transport Service (NWTS)
3.7.1 NWTS was set up to transport by ambulance any critically sick or injured child from general hospitals to the nearest paediatric intensive care unit (PICU). The service provides paediatric specialist NHS staff (doctors and nurses) to manage the care during transport, as well as advice support on patient management before transfer or when transfer is not possible.
3.7.2 The IMR was written jointly by the lead consultant and lead nurse and countersigned by the Clinical Nurse Manager. The report is based on written reports, telephone records and interviews with staff.
3.7.3 The service contact with Child 1 was brief from the first contact to when the handover to Hospital 3 PICU took place. The timing of the call meant that two teams of staff were involved, the daytime team handing over to the night team. The first team spoke to the family on arrival at Hospital 1, and the night team spoke to them on arrival at Hospital 3.
3.7.4 The narrative in the IMR notes that the consultant at Hospital 1 was asked to check if Child 1 was known to the local safeguarding team, because of the uncertainty of the cause of the cardiac arrest although the notes of examination are clear that there was no external sign of NAI. It is noted in the chronology as well as the narrative that the possibility of NAI was discussed at handover to Hospital 3.
3.7.5 The service always follows up to find out the progress of patients within 24 hours of the transfer. NWTS was told Child 1 was very poorly and later notified of the death, and the referral to the Coroner.
3.7.6 The IMR notes that recording for Child 1 did not meet the expected standard, as two sets of documents had been completed. The second set made an assumption that history taking and examination had been completed prior to arrival at Hospital 3. Also the paperwork, although safeguarding concerns had been highlighted as a possibility, did not record what action had been taken to refer to the relevant agency. Additionally the review identified that the driving staff at present do not have any safeguarding training.
3.7.7 All three of these points have been included as recommendations for the service.
3.7.8 The IMR is not presented in the same format as other IMRs, but because of the limited contact with the family, all the necessary information is evident in the report.
3.8 Hospital 3 NHS Foundation Trust
3.8.1 Hospital 3 NHS Foundation Trust is one of two specialist Paediatric Tertiary Centres in the North West of England providing medical care for very sick children. The paediatric intensive care unit regularly manages the care of children who then become the subject of SCRs and so has in place procedures that recognise the uncertainty that can surround the cause of admission.
3.8.2 The addendum IMR was prepared by a Nurse Consultant, the named nurse for Safeguarding Children and countersigned by the acting Director of Nursing and Executive Lead for Safeguarding. It was agreed that Terms of Reference used by other IMR authors were not fully relevant; instead the IMR (referred to as an addendum IMR for this reason) used the following questions for analysis:-

  • What opportunities did the agency have to observe parenting ability and interaction between Adult 1 and Adult 2?

  • What impact did this have on assessments, actions and services at the time and were these all appropriate?

  • On reflection were there any signs or indicators that Child 1 was at risk of suffering significant harm?

  • Did all agencies and professionals give due and proper consideration to all diversity issues, including ethnicity, religion, language, disability, culture, social background and integration?

  • Did all agencies keep the child and their experiences at the centre of their assessments of and interventions with the family?

  • Were information sharing and communication systems within and between agencies and across boundaries effective?

  • Was record keeping and documentation of an adequate standard?

To prepare the report the author used the paper and electronic records created at the hospital and the NWTS transfer information.

3.8.3 The report gives in detail not only all the medical interventions and notes of Child 1’s deteriorating condition, but also every communication between staff and between staff and the family. Child 1 was admitted and died shortly after with parents present.
3.8.4 The report demonstrates the care taken to ensure all possible causes of Child 1’s collapse could be investigated, including non-accidental injury, at the same time allowing the family members to be with Child 1 and to grieve.
3.8.5 On admission it was known that because it was 50 minutes before Child 1 could be resuscitated following the cardio respiratory arrest, it was unlikely that the child would live. The family had been prepared for this by staff at Hospital 1 and this continued at Hospital 3. Adult 1 stayed with Child 1 during the night, while the rest of the family (Adult 2, Adult 3, Adult 4 and Child 2) returned home.
3.8.6 As part of normal procedure for an unexplained collapse, Child 1 was referred to the ophthalmologist. This showed evidence of retinal bleeding that was not caused by the prolonged resuscitation. Hospital 3 had already notified Bolton Children’s Services of the life threatening condition, that Child 1 was likely to die and that the SUDI protocol would be followed. During the afternoon, a further call was made to Bolton Children’s Services. The checks showed that neither Child 1 nor Child 2 was known to Social Care.
3.8.7 The specialist resource at Hospital 3 means that very poorly children are regularly admitted in unexplained circumstances. Experience has shown that preparing staff and the family for any type of investigation into the causes prevents both distress to family members, and possible interference of evidence at an early stage. This has led to the inclusion of action to be taken in the SUDI protocol called the Acute Life Threatening Episode (ALTE). This addition, with an ALTE pro-forma to complete is accepted across the Area 5 authorities.
3.8.8 Hospital 3 began the implementation of this procedure with notification to Safeguarding Consultant 1. The purpose of the procedure was explained to the family and information collected (by Safeguarding Consultant 1) from them to contribute to the records. Later in the day, Safeguarding Consultant 3 explained that the matter would be referred to Children’s Services and the police. Safeguarding Consultant 3 telephoned Bolton Children’s Services on the morning to confirm the information about Child 1’s death, referral for a post mortem and notification to the Coroner, following the SUDI protocol.
3.8.9 Child 1’s family were only in contact with Hospital 3 for 24 hours. During that time, Adult 1 and Adult 2 spoke freely of their life when living with Adult 4 and their concern that he would take over the arrangements for their baby. Adult 2 was described by Adult 4 as having the mental age of 12, but Adult 1 described him as ‘lagging behind by two years’. During all the conversations, Adults 1 and 2 seemed to understand the staff concerns, and presented as caring parents.
3.8.10 The report demonstrates that staff were aware of Adult 2’s learning difficulty, and that English is not Adult 1’s first language. All communication was given in a simple form, in Hindi when requested and was only shared with the wider family with the consent of Adult 1 and 2.
3.8.11 Hospital 3 has a Child Protection policy ensuring the needs of any child are paramount; as Child 1 was very poorly from admission, nursing was provided on a one to one ratio, so care was safeguarded at all times. However this is balanced by the Trusts challenge to meet the twelve principles of a good death as defined in their hospital procedures. As Child 1 could not communicate in any way, the staff ensured that parents were in close contact at all times. Also the bereavement policy ensured the parents were able to cuddle, wash, take photographs, and take away imprints of Child 1’s hands and feet.
3.8.12 Overall the IMR demonstrates full adherence to the procedures, inclusion of the family and sensitivity to the issues presented by the extended family, while remaining focussed on nursing and treating a very sick baby who was likely to die.
3.8.13 The review of records identified two inappropriate records. One staff member, Safeguarding Consultant 2, had recorded them as ‘lovely and devastated’. The IMR notes that this is a subjective statement, which should not be part of the factual record. A second concern was an electronic entry by a nurse that there were no safeguarding concerns when an earlier paper record notes the query of the retinal haemorrhages in the right eye.
3.8.14 Hospital 3 had notified Bolton Children’s Services early that the SUDI protocol would be implemented following the death of Child 1. However when the call was made to notify of some safeguarding concerns following the Area 5 ALTE procedure there was an expectation that Children’s Services would notify the local police to ensure consideration of protection of a possible crime scene. There is no similar protocol in the remainder of the North West and the response in Greater Manchester is to wait until the notification of death or confirmation of NAI before involving the police.
3.8.15 The IMR has two recommendations linked with the points made in paragraphs 3.8.13 and 3.8.14, to improve standards of record keeping by including such examples within the safeguarding training, and to work with agencies in the North West, including NWTS to adopt the principles and actions from the Area 5 ALTE procedure.
3.9 The NHS Bolton Commissioning Report
3.9.1 The NHS Bolton Commissioning report has been jointly prepared by the Associate Director of Safeguarding (Designated Nurse) and a Consultant Paediatrician (Designated Doctor) from NHS Bolton and countersigned by the Interim Accountable Officer from the Commissioning Group for Bolton.
3.9.2 The authors have used the five NHS IMRs as the basis of the NHS Commissioning Health Report as well as:-

  • Feedback and comment from panel discussions on each IMR

  • A training meeting for NHS IMR authors

  • Discussion with the Lead Commissioner for the regional PICU service to gain agreement to include the Hospital 3 IMR in the report

  • An analysis of the integrated health chronology

  • Consideration of practice standards

  • Additional review of health visiting records, particularly those transferred from Area 4 to clarify how care was provided to Child 2, prior to the move to Bolton

3.9.3 The authors note at the beginning of the report that it had been difficult to prepare the NHS chronology as the region uses a different template from Bolton. Following discussion at panel, it was agreed that the differences should be discussed at the LSCB and any relevant action taken.

3.9.4 The NHS Commissioning Health report is written in a clear, simple style. It outlines the contact the family had with NHS services and where appropriate considers whether the service has fully met practice standards. Any evidence of not meeting standards is limited but is important to consider. The report considers as more than meeting practice standards:-

  • Quality of the health visitor ‘movement in’ visit

  • Service provided by both GP practices, especially the prompt appointment service for babies and young children

  • Wider assessment provided by the ophthalmologist leading to a referral to a paediatrician

  • Role of the health visitor in making referrals for therapy services and follow up on progress

  • Transfer and communication between health visiting and midwifery services

  • Quality of the midwifery service

  • Quality of the primary health visiting visit following Child 1’s birth

  • Emergency services provided by NWAS and NWTS, including excellent response times

  • Services provided by Hospital 3

3.9.5 Overall the authors are able to report that the family was provided with a good quality service, and a particularly sensitive service during the time of delivering acute emergency services.
3.9.6 The NHS Bolton Commissioning Report, following the commentary on the description of events, identifies five themes for consideration that link with the terms of reference. These are:-

  • Communication

  • Plurality of vulnerability factors in the family and assessment

  • Cultural issues

  • Learning difficulties

  • Domestic abuse

3.9.7 In the introduction to the Themes, the authors note that while within the review, participants can use hindsight, it is important to only make judgements on practice based on the information available at the time. Within the comments against each theme the authors cross reference them against each of the eight terms of reference. However the terms of reference are not specifically addressed limiting cross reference in section 4 of this report.

3.9.8 In the commentary the report notes that the majority of contacts and service provision met all expected standards, for example the detail recorded in health visiting assessment visits, referrals for speech and language therapy, specialist dietary advice, and checking how well the family were able to follow advice. The Commissioning Report commented on this good practice, but notes three areas where judgements could have been different as described in paragraphs 3.9.10 to 3.9.15 below.
3.9.9 The information recorded by the GP about domestic abuse was not given to the Health Visitor, nor coded as an alert, or referred to Social Care. During health visiting visits the matter of personal safety was properly raised but without Adult 1’s disclosure, or some indication of her situation, the health visitor was not in a position to pursue Adult 1’s responses.
3.9.10 One of the authors of the Commissioning report has checked carefully the notes transferred from Area 4. There is no indication of any domestic abuse between the adults in the extended family. With hindsight, the information suggests a level of acceptance within the family of some violence. The Commissioning Report notes that the GP IMR identifies that some action should have been taken, and recommends closer liaison between Health Visitors and GPs as there should have been some consideration of the impact of the domestic abuse on Child 2.
3.9.11 The omission of giving information to the health visitor was further exacerbated when during the pregnancy of Child 1, both parents were reported to be pleased. Not knowing that Adult 1 had told the GP that she did not want another pregnancy, while Adult 2 did, prevented the midwife from checking more carefully with Adult 1. In hindsight, staff can see that potentially Adult 2 had a controlling role.
3.9.12 The point in paragraph 3.9.9 is also pertinent for NHS staff responses when Adult 1 discussed that Adult 2 was seeing someone else and that they were planning to separate. Community NHS staff had established a good rapport with both adults, and Adult 1 and 2 began to talk about their experiences with the extended family in Area 4. The staff would have had a more complete picture if they had known about Adult 1’s separate concerns and they would have been able to consider the impact on Child 2 and the expected baby. The NHS Bolton Commissioning Report notes that no other agency had either alerted the staff to any concerns or asked for information as they were concerned.
3.9.13 However, while the omission was regrettable, it is not the view of the NHS Commissioning authors, or the panel, that even with greater efforts to check that Adult 1 was able to talk about any difficulties in her marriage, there would have been a different outcome.
3.9.14 In relation to NHS community staff the last area considered is the lack of information on Adult 2’s learning difficulty. Again the authors checked the information transferred at the time from Area 4 Community NHS records. There was one reference, within the notes to his learning difficulty, but the information was not included in the summary as a factor relating to his parenting capacity. This summary is used to highlight any particular needs, issues or concerns. None of the NHS staff who met Adult 2 were aware that he had a learning difficulty, and there is no suggestion that the difficulty had an impact on his parenting. In fact there are positive comments on the relationship between Adult 2 and Child 2.
3.9.15 The NHS Bolton Commissioning Report comments on the prompt and responsive service provided in the emergency by both NWAS and NWTS. However there was a delay in notifying the police of the unexplained injury as it was not done by NWAS as expected. Hospital 1 did not check the notification had been made by NWAS, nor did NWTS. The police only became aware of the possibility of an unexplained serious injury or death when Children’s Services notified them. While in this instance the timing was not crucial, in some circumstances the police can only complete investigations properly and promptly if a notification is made at the earliest opportunity. This is recognised in the individual IMRs and the Commissioning report.
3.9.16 When Child 1 was transferred to Hospital 3, because of the unexplained nature of the cardiac arrest, the hospital followed their procedure for ALTE. As noted in paragraph 3.8.14, this procedure is not in place across the whole of the North West. This led to a misunderstanding between Hospital 3 and Bolton Children’s Services. In discussion in panel, there seemed to be a further lack of clarity in the procedure. The notification from Hospital 3 to Bolton Children’s services, after the ophthalmologist had identified retinal haemorrhaging, was intended to trigger notification to the police. In fact the notification to the police was only made after Child 1’s death. The detail of the expectations of the pro-forma will need to be clarified, if as recommended it is accepted as a regional procedure.
3.9.17 Theme 1 – Communication
The conclusions identify some lack of communication which can be improved. These are:-

  • Information sharing between GP, the health visiting service and Children’s Social Care should include key factors that could impact on parenting; the GP IMR has a recommendation to remedy this point and since the death of Child 1, this is included in the NHS Bolton Safeguarding Policy

  • Notification to the police when a baby has an unexplained condition that could have been caused non-accidentally. As non-accidental injury must always be a possibility, individual IMRs have made recommendations, and the NHS Bolton Commissioning report makes two recommendations linked with this issue. One is that BSCB and NHS Bolton should ask Greater Manchester to adopt a similar ALTE pro-forma, and the second that NHS Bolton should use the pro-forma within local services.

3.9.18 Theme 2 - Plurality of vulnerability factors in the family and assessment

The report considers the strengths of both parents observed by NHS staff. Until Adult 1 talked to the health visitor about her marriage, and her loneliness, there was little indication of vulnerability. The report refers to research that indicates the vulnerabilities known to the service, even with the additional information from the visit to the GP, it would not reach a threshold for a family action or child protection meeting, but did meet the threshold for additional support.
3.9.19 The report also comments that most of the health visiting visits were undertaken by a staff nurse. Supervision from the health visitor should have reviewed the support needed by the family and the health visitor should have considered completing a CAF. This is included as a recommendation in the Bolton NHS FT IMR.
3.9.20 Theme 3 - Cultural issues
The report notes that information on the extended family in Area 4 which would have provided a fuller context for the situation of Adult 1 in particular but also Adult 2 was not included in the transfer notes. However even though the extent of Adult 2’s learning difficulty was not known or the degree of isolation Adult 1 was experiencing, NHS staff could have provided some information and guidance on community support. In Bolton with a large and mixed cultural population there are many opportunities for women to gain support from the community in culturally sensitive groups.
3.9.21 All the NHS staff recorded good language skills, and the health visitor checked that Adult 1 could understand the more complex information in the dietary advice with the use of an interpreter. In Area 4, the records indicate Adult 4 translated for Adult 1, but with hindsight this is noted as a possible controlling action.
3.9.22 There are no recommendations linked with cultural issues, as the staff recognised the needs of Adult 1 and had taken action to support her.
3.9.23 Theme 4 - Learning Difficulties
The report notes that no health professional observed any concern about Adult 2’s ability to parent. He had sole care of Child 2 on a number of occasions. Learning difficulty is not a key indicator of safeguarding concerns, (noted the overview of Serious Case Reviews, found it a factor in 15% of cases), and the conclusion is that it did not have an impact with Adult 2. However his learning difficulty may have had an impact on Adult 1’s feelings of isolation. A wider conclusion is that fathers should be routinely included more in discussion of child health.
3.9.24 Theme 5 - Domestic Abuse
The response to the one record of domestic abuse does not meet the expected standards within the LSCB procedures. The omission of not passing on the information has been noted in detail in the report, but the NHS Bolton Commissioning Report concludes that it also points to the wider concern of the lack of engagement by GP practices in child in need and child protection procedures. In this case the lack of information about the behaviour of Adult 2, and the experience of abuse in Area 4 meant that assessments of Child 2 did not take any account of domestic abuse but that the service offered to Adult 1 and the children would not have differed. Adult 1 was asked at least twice if there was any domestic abuse, and had the opportunity to speak more easily when the interpreter was present.
3.9.25 The NHS Bolton Commissioning Report draws some general conclusions that are reflected in the individual IMRs and makes four recommendations, linked with the commentary in paragraphs 3.9.10 to 3.9.13. These are:-

  1. Greater Manchester LSCBs and NHS Greater Manchester amend the current Protocol “Sudden Unexpected Deaths in Childhood to include guidance on the management of a child suffering from an ‘Acute Life Threatening Event’ (ALTE). This will ensure a consistent response by agencies to notifications of children experiencing a life threatening event where non accidental injury is always a differential diagnosis.

  1. Bolton Foundation Trust to consider adopting the ALTE pro forma for use in children who remain in Bolton for their investigation and treatment. This should specify explicitly who will be contacting each agency involve and when this has been done so that there is no delay in involvement of any individual agency.

  1. Hospital 3 to review the ALTE pro forma to include an explanation about what ALTE protocol requires for areas that do not have an operational ALTE protocol and agree and document which agency will take responsibility for notifying the Police as the existing protocol only states that the Police must be informed.

  1. Raise awareness of the impact of additional stressor including poor housing, social isolation, poverty and domestic abuse on parents with particular regard to parents with learning difficulties. This recommendation relates to frontline health workers responsible for assessing children and family’s needs and also managers responsible for clinical supervision.

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