Meha Carneiro
3 Apr 2024 · Coroner Elizabeth Didcock · Nottingham City and Nottinghamshire
The coroner's concerns
1. insufficient trained paediatric nurses in ED
“There were insufficient trained Paediatric nurses on duty in the Emergency Department (ED), on the day of [the deceased]'s admission, and there was no effective escalation to senior nursing staff to highlight this”
2. lack of recognition of patient deterioration
“There was overall a lack of recognition of how unwell [the deceased] was on admission and over the subsequent hours prior to her death- this included both nursing and medical staff in ED”
3. inadequate PEWS review threshold
“Whilst switching from use of POPS to PEWS in ED, is likely to assist in ensuring repeat observations in a sick child, a PEWS of 6-8 only triggers review by a junior rather than a senior ED Doctor, the former less likely to recognise severity of illness and respond appropriately”
4. ineffective handover and documentation
“There was insufficient and ineffective handover between medical staff, with lack of documentation of key information, and agreed clinical plans- between doctors in ED, and between ED and Paediatric staff”
Responses
2024-0187-Response-from-Sherwood-Forest-Hsopitals-NHS-Foundation-Trust.pdf ↗· Sherwood Forest Hospitals NHS Foundation Trust
Stated action · October 2024
“A profile of when children and young people attend the ED over a 1-year period has been obtained to ensure that RNCs are rostered on at peak times.”
Stated action · July 2024
“A new band 7 supervisory Nurse in Charge (NIC) role has been implemented within ED to ensure there is now visible senior support available 24 hours a day for the entire department.”
Stated action · October 2024
“Continuous collaborative working between ED and the division of Women and Children to develop a rotation pathway for RNC's is planned to be in place by October 2024.”
Stated action · Ongoing
“The ED children's area rota is produced by the band 7 lead nurse a minimum of 6 weeks in advance.”
Stated action · Ongoing
“A minimum set of core competencies that adult nurses must have completed prior to caring for a child or young person has been agreed as follows: a. Minimum of 18 months post registration experience b. Completion of Paediatric intermediate life support training c. Completion of the internal 2 day paediatric study days d. Completion of paediatric sepsis e-learning package e. Following completion of the above, an additional day shadowing a trained Registered Children's Nurse will be completed.”
Stated action · Ongoing
“Children and Young People (GYP) escalation tool has been reviewed to ensure there is clear guidance on escalation triggers and the actions required.”