1. General Practitioners need to be aware that there is a risk of invasive Group A Streptococcal disease during an influenza epidemic / pandemic. For those children who require oral antibiotics I would follow the Department of Health Flu guidelines which recommend Amoxicillin as first line. I would reserve a 10 day course of Penicillin for those children who have signs suggestive of GAS i.e. high fever
with sore throat with/without classic rash. Restricting the use of non-steroidal anti- inflammatory drugs such as ibuprofen is more controversial. Ibuprofen helps a lot of children with simple viral infections and sore throats. In children who are admitted to hospital with obvious toxic shock, its use may be limited, but again the evidence for this is contradictory.
2. I think it is important that GPs consider measuring heart rate in pre-school children as part of their routine practice — tachycardia in the absence of fever in an ill child is an important sign not to be missed. Assessment of urine output is also important in the assessment of hydration. The GPs at Cricketfield Surgery have been deeply saddened and troubled by Samuel’s death and have taken time to reflect upon their practice. The Spotting the Sick Child internet teaching tool produced by the Royal College of Paediatricians and Child Health is helpful in consolidating one’s knowledge and the practice will be meeting before this winter to review any advice from the Chief Medical Officer in the treatment of children and adults with influenza.
3. Mr and Mrs Morrish very much wish for the Surgery to review the processes that underpin their telephone triage service — is there a ‘fast track’ process for sick children? Are all calls dealt with sequentially? The parents would like clarification regarding this.
4. The tragic sequelae of events following Samuel’s review by [the Second GP]
highlights to me the importance of making robust follow-up arrangements. NHS Direct is in essence a triage service who skilled operators often have no prior knowledge of the case and deal with questions as they are presented to them. In Samuel’s case the focus on vomiting meant the
nurse advisors clinical impression will have been skewed. Nonetheless, if there is any suggestion of a gastrointestinal bleed this is a medical emergency and should be admitted to hospital. The vomiting algorithm has now been amended with direct referral to hospital as an outcome measure.
5. Mr & Mrs Morrish were under the impression that the decision
recommending Newton Abbot Treatment Centre over Torbay Hospital was a clinically derived one. This was subsequently found not to be the case. Again decisions were made for practical geographical reasons and with good intention (Newton Abbot Treatment Centre was very close to the Morrish’s and was on the way to Torbay Hospital) but was not based on clinical reasoning.
6. Resuscitation of children with invasive Group A Streptococcal disease needs to be prompt and aggressive to maximise the chance of survival. It is easy in retrospect to say when this should have happened but by the time Samuel presented to Torbay A&E he was already very unwell. He did initially respond to fluid resuscitation. Earlier administration of antibiotics, therapies directed at neutralising
endotoxins eg Clindamycin/intravenous immunoglobulin, earlier intubation and ionotropic support may have helped Samuel to survive. The majority of this care would have had to have occurred on an Intensive Care Unit. Torbay Hospital has a children’s High Dependency Unit and one bed on an adult ITU which is used to stabilise children prior to transfer to a larger paediatric intensive care unit — the nearest from Torbay being Bristol. Given that Samuel had signs of decompensated shock in the early hours of the morning, elective intubation at that time and
transfer in an ambulance to a PICU would also have been associated with a high risk of mortality.
Unlike the non-blanching rash seen in meningococcal disease (that can be looked for using the ‘glass test’), there is no obvious symptom or sign in the early stages of invasive Group A streptococcal infection that is
pathognomonic. To detect this disease we are therefore reliant on good surveillance by primary physicians, robust follow-up arrangements for ill children and prompt and aggressive resuscitation in severe septicaemia. Rest in Peace, Samuel.
[Name of]
Consultant Paediatrician 30/08/2011
4. Family care review
4.1
Parental experience
A lack of bereavement support for both parents and Sam’s older brother has been recounted by Mr and Mrs Morrish (narrative account from Mr Morrish sent to [name] 23/06/2011). Mr Morrish recounted the kindness and compassion shown by the Chaplain, who drove him and his wife home in the early hours of 23/12/2010.
Despite initial contact from the GP Surgery (via Sam’s grandmother) and [the consultant paediatrician], the Morrish family report the absence of personal, face to face bereavement support. The family report a catalogue of contacts instigated by them to the GP and Consultant Paediatrician over a five month period, culminating in an approach to the Chair of the RCA Process.
The result of the latter contact was the beginning of bereavement support for Sam’s brother being identified through [name], Health Visitor, Devon PCT. Mr Morrish has acknowledged the apology received from [name] for the mistakes that were made regarding communication between the Public Health Nursing Team and Sam’s brother’s school and is grateful for the help provided specifically for Sam’s brother. With regard to bereavement support and counselling for Mrs Morrish, after repeated requests to the GP surgery, the family report receiving a national list of registered counsellors rather than a local contact which would have been much more helpful. Mrs Morrish described her frustration at not being able to identify whom she should contact, with no
knowledge of which individual from the national list might be skilled in the field of bereavement counselling.
Mr and Mrs Morrish report requesting bereavement support, especially for Sam’s brother from the GP practice - “They told us that although they, as GPs could not help, they could in their own words ‘signpost us: that’s what we do’ [the First GP]. For us this was a relief. So we waited.”
A three month period elapsed and although Mr and Mrs Morrish report they were sent an email from the GP practice on 8 March containing a list of websites, what they wanted and needed was a person to talk to, who was experienced in bereavement counselling and able to help with an unexpected traumatic child death (Mr Morrish narrative account — accessing bereavement support/counselling through the NHS).
Mr and Mrs Morrish report what they perceive to be confusion relating to whose responsibility it was to organise initial and ongoing bereavement support for themselves and, importantly, Sam’s brother -
“For months, we got the feeling that the GPs thought the hospital should have helped us, because that is where Sam died. For months, we got the feeling that the hospital thought that the GPs should be the people to help us, because they were our GPs. For months no one mentioned anything to the Public Health Nursing Team and for months — we have not been given the help we were asking for” (Mr Morrish narrative account).
They described their experience as frustrating and confusing leaving them expressing -
“It felt like no-one cared...we felt helpless, angry and isolated. Support should have come from one of the agencies, an advocate, someone consistent” (Meeting with Reviewer 22/07/2011).
Mr and Mrs Morrish reported unanswered questions in relation to the Child Death Overview Process and whether it was followed in Sam’s case.
4.2
National Guidance
The HM Government document
Working Together to Safeguard
Children (HM Gov 2010) outlines the
processes to be followed in the event of an unexpected child death. This guidance intends that the relevant professionals and organisations work together in a co-ordinated way, in order to minimise duplication and ensure that the lessons learnt contribute to safeguarding and promoting the welfare of children in the future. Care of the family forms a central component of the guidance in relation to unexpected death and states -
“It is intended that those professionals involved (before and/or after the death) with a child who dies unexpectedly should come together to respond to the child’s death....The work of the team convened in response to each child’s death should be co-ordinated, usually, by a local designated paediatrician responsible for unexpected deaths in childhood. The joint responsibilities of these professionals include -
• responding quickly to the unexpected death of a child;
• making immediate enquiries into and evaluating the reasons for and circumstances of the death, in agreement with the coroner;
• undertaking the types of enquiries/ investigations that relate to the current responsibilities of their respective organisations when a child dies unexpectedly. This includes liaising with those who have ongoing responsibilities for other family members;
• collecting information in a standard, nationally agreed manner (see paragraph 7.2 and footnote 118); • providing support to the bereaved
family, and where appropriate referring on to specialist bereavement services; and • following the death through and
maintaining contact at regular intervals with family members and other professionals who have ongoing responsibilities for other family members, to ensure they are informed and kept up-to-date with information about the child’s death.”
HM Gov 2010 pp220 — 221) The guidance proposes that a case discussion meeting should be held once the final post mortem result is available. The main purpose of the case discussion is to share information to identify the cause of death and/or those factors that may have contributed to the death, and then to plan future care for the family
4.3
Local guidance and process
4.3.1 Child death overview process
At the time of Sam’s death, across the Southwest Peninsula, local translation of the national guidance was in operation; Peninsula Child Death Overview — Protocols and Working Procedures [January 2009]. The afore mentioned document details processes for notification of all death of children under 18 years of age to the Peninsula Child Death Overview Panel [CDOP] Office. In an Acute Trust, the document states, the Child Death Overview Coordinator should be informed of the death as soon as practicable.
From discussion with the Rapid Response Practitioner [telephone conversation 03/08/11] and the Peninsula Child Death Review (CDR) Service Manager [telephone conversation 18/08/11] the reviewer understands that standard practice following a rapid response referral is - • Call received
• Contact made between Rapid Response Practitioner [RRP] and referring paediatrician. A decision is made determining if a Rapid Response is appropriate — this is determined using set criteria including if the death is unexplained as well as unexpected.
• If Rapid Response referral is accepted:
• RRP attends hospital, reviews medical notes and speaks to clinicians
involved
• RRP contact made with family and home visit arranged; usually same day
• Following home visit, single point of contact established between RRP and family
• RRP contact with other agencies, such as GP, Health Visitor to access support for the family
• Consideration made of need for Strategy Meeting — this is a meeting of professionals involved in the child’s care. All agencies involved in the child’s care are identified. A review of the events surrounding the death are considered, together with coordination of reports to be made available for the Local Case Review • Local Case Review meeting organised
for a date following the Post Mortem report availability
• Family informed of date for Local Case Review Meeting. RRP discusses with the family if there are any key issues, from their perspective they feel should be addressed at the Local Case Review meeting
• Local Case Review meeting held. Recommendations made and report presented to the Child Death Overview Panel
• Family made aware of the outcome of the Local Case Review.
If a Rapid Response is determined inappropriate, the Paediatrician is assumed to be the lead professional in terms of ‘duty of care’ for the family. In the event a Rapid Response is not initiated, the Child Death Overview Panel will still review the child death, but this may not occur for many months, as they will wait for the post mortem and inquest findings to be available.
If when the child death is considered by the Child Death Overview Panel, learning or concern is expressed relating to care provision, the CDR Service Manager informed the reviewer that an approach would be made to the commissioner of those services. Any information arising from the Child Death Overview Panel would be available for use in the commissioner led investigation.
The CDR Service Manager informed the reviewer that the CDOP practitioners are not themselves bereavement counsellors and she perceived there to be a gap in terms of bereaved parents accessing bereavement support following the death of a child.
4.3.2 South Devon Healthcare NHS
Foundation Trust
South Devon Healthcare NHS Foundation Trust [SDHFT] - the reviewer requested from SDHFT any bereavement policies or guidelines relevant to child death. The Dying Child — Bereavement Guidelines were supplied. The guideline proposes the identification of a co-ordinator; a senior nurse, middle grade doctor or consultant to “ensure that the necessary people are informed, and necessary tasks undertaken”. The guideline states that the checklist within the guideline should be completed by the co-ordinator and retained in the medical notes. The checklist includes consideration of other professionals that need to be informed, such as the Health Visitor.
4.4
The Morrish family care review
4.4.1 Child death overview process
Following Sam’s death on 23/12/2010, a notification form was completed by South Devon Healthcare NHS Foundation Trust (SDHFT) and it is reported that this was emailed to the Southwest Child Death Overview Panel office on the same day. Whilst a Rapid Response Referral was not made, the reviewer is informed that a conversation between the CDR Service Manager and the Consultant Paediatrician took place on 23/12/2010. A decision was made at this point that a Rapid Response was not appropriate as whilst Sam’s death was unexpected, it was not unexplained, such that the suspected cause of death was flu complicated by septicaemia. Therefore, in line with CDOP process detailed above, the Paediatrician
assumed the role of lead professional in terms of ‘duty of care’ to the family. From analysis of the organisation reports, there is evidence that the Paediatrician informed the GP of Sam’s death on 23/12/2010 via telephone (see timeline, Annex A), It is not clear however, if bereavement support was discussed at this point. A letter was also sent to the GP dated 30/12/2010 from the Paediatrician informing the GP of the post mortem findings. The letter also highlighted that the Paediatrician would be in touch with the family in two weeks hence, to arrange for the family to meet with the Paediatrician to address any unanswered questions the parents had. It is evident that the Paediatrician maintained contact with the family, either via telephone or meetings on 30/12/2010, 17/01/2011, 30/03/2011 (meeting requested by Mr
Morrish) and 06/05/2011 where the Paediatrician met Mr and Mrs Morrish accompanied by MP, from the Child Death Overview Panel office.
4.4.2 Bereavement support
In line with the afore mentioned guideline, the South Devon Healthcare NHS Foundation Trust [SDHFT] medical notes record that the Bereavement Office phone number was given to Mr and Mrs Morrish on 24/12/2010. Mr and Mrs Morrish had in their possession a leaflet they had been given from the Bereavement Office when the reviewer met them.
Within the case bundle of papers supplied to the reviewer, a statement from a Staff Nurse caring for Sam reports the presence of a Minister at the parent’s request shortly after Sam died
There is no evidence of the checklist in the SDHFT medical notes supplied for the purpose of the independent review. The RCA Investigation report from SDHFT identified an action from its analysis of the events surrounding Sam’s death relating to improving the provision of bereavement information for parents following the death of a child. This point is further reiterated in the SDHFT summary of learning and actions taken following Sam’s death (Section 6).
A Clinical Psychologist referral was made by the Paediatrician following a meeting requested by Mr and Mrs Morrish at the end of March 2011. The referral letter, dated 01/04/2011 was copied to the GP. With regard to bereavement support for Sam’s brother, Mr Morrish reports
receiving an apology from the Health Visitor for confusion in communication between the Public Health Nursing Team and Sam’s brother’s school; the result of which led to no contact established between the Public Health Nursing Team and the family.
The GP surgery contacted the family following Sam’s death but conversed with Sam’s grandmother in the first instance. It appears that the GP surgery did not discuss bereavement support at this point. There is evidence that one of the GPs visited Mr and Mrs Morrish at home on 17/01/2011 but again it appears that bereavement support was not actioned as a result of this visit. Following a meeting between Sam’s parents and the GP surgery later in January, Mr Morrish reported that the GP surgery had agreed to ‘signpost’ them to bereavement support agencies. The GP surgery acknowledge the
significant delay in providing guidance with regard to bereavement support and outline that more information should have been freely available between the hospital and the surgery with respect of who was responsible for initiating bereavement support (Organisational Learning, Section 6).
4.5
Family care review — summary
findings
• Notification of Sam’s death was made to the Child Death Overview Panel Office on 23/12/10.
• Following a decision that a Rapid Response Referral was not indicated, the Paediatrician assumed the role of lead professional in fulfilling a ‘duty of care’ to the family following Sam’s death.
• South Devon Healthcare NHS Foundation Trust has a bereavement following the death of a child
guideline. There is evidence of partial implementation of the guideline; there is no evidence of the checklist in the supplied medical notes. • Following Sam’s death, details of
the SDHFT Bereavement Office were given. SDHFT identified an action from its analysis of the events surrounding Sam’s death relating to improving the provision of
bereavement information for parents following the death of a child.
• The Paediatrician informed the GP of Sam’s death but it is not clear whether bereavement support was discussed or who was to provide it. As a consequence, Mr and Mrs