Trust ‘missed opportunities’ in child’s death

A report into the death of five-year-old Yusuf Nazir found the use of “multiple systems and formats”, including paper documents, across four organisations contributed to “fragmented and disjointed care”.

Yusuf was taken to Rotherham Hospital’s A&E in November 2022, after his GP prescribed antibiotics for a suspected case of tonsillitis. He was sent home from the hospital and the family subsequently called an ambulance to take him to Sheffield Children’s Hospital when his condition worsened.

At the specialist centre, he was admitted to a ward on the Friday, but deteriorated further over the weekend and was transferred to paediatric intensive care three days later. He died on 23 November after multiple organ failure and several cardiac arrests.

The investigation was commissioned by NHS England, following the family’s concerns about a previous exercise. It was led by Peter Carter, a former trust chief executive and secretary of the Royal College of Nursing, along with consultancy Nurture Health and Care.

The review was tasked with looking at parental involvement in decision-making and “systemic factors that may have influenced the delivery of care”.

It found that treatment by the GP surgery, Rotherham emergency department and Yorkshire ambulance service was in line with clinical guidelines and Yusuf’s presentation, adding that Yusuf’s presentation was “atypical” and therefore not identified within usual monitoring systems.

However, the review said care at Sheffield Children’s Hospital across the weekend “did not meet the standards to be expected” and warned of “missed opportunities” for escalation.

It said: “Although clinical contacts continued over the weekend, the absence of consistent senior medical review, possibly delayed diagnostic decision-making, and a lack of clearly documented escalation decisions reflect the system-wide challenges associated with care.”

The report calls for national bodies to support “sustainable consultant oversight across seven-day services, particularly in paediatrics”, including “realistic models for weekend medical review”.

The review also criticised the lack of joined-up medical records across organisations, which has been found in other patient safety investigations.

It said: “Yusuf was overseen by more than 30 clinical contacts with at least 23 different professionals across multiple healthcare organisations. These contacts occurred over an eight-day period, including a weekend, yet there is no ability in our current systems to create a single, continuous plan of care or a centralised record accessible to all professionals involved.

“Records were kept on both computer systems but also in SCH included paper records, which created barriers to share essential clinical information. The use of multiple systems and formats further impaired shared understanding of Yusuf’s clinical status, progression, and decision-making.”

It called for a national review of the use of paper-based records in paediatric care due to the impact this can have on “continuity and safety”.

Unheard and downplayed

The main conclusion from the report was that the family’s warnings “went unheard or were downplayed”. The report acknowledges that staff are under pressure which can lead to “perfunctory and focused assessments” but concludes the family’s warnings were repeatedly “unheard or were downplayed”.

“The child’s mother sought help at every stage… yet her observations were often minimised,” it states.

Yorkshire Ambulance Service has also been asked to ensure its staff are trained to “recognise and respond effectively to diverse cultural needs”, after the review said the “behaviour and attitude” of the crew attending did not meet expected standards.

One of the review team wrote: “I further believe the behaviour of the crew had a significant impact on the patient and family experience, in what was clearly already a very stressful situation.”

HSJ asked Yorkshire Ambulance Trust what actions were taken in response to this finding. Peter Reading, YAS CEO, said: “These recommendations provide further opportunity to learn and improve, and our focus will be to build on the progress already made in these areas, developing our training and ensuring all of our staff are following the policies, procedures and guidance already in place.”

SCH confirmed it was reviewing its weekend oversight and said it had introduced a number of improvements to address concerns about documentation, escalation and medication. Jeff Perring, SCH medical director, said: “We are dedicated to delivering the improvements outlined in the report’s recommendations.”

Jo Beahan, The Rotherham Foundation Trust medical director, said: “Our deepest sympathies remain with Yusuf’s family following such a sad loss of a loved family member. We fully cooperated with this investigation into Yusuf’s care.

“We have taken steps to address the recommendation and also the concerns raised by Yusuf’s family. Our thoughts continue to be with Yusuf’s family.”

Aidan Fowler, NHS England national director of patient safety, said the failure to listen to the family was “unacceptable”. Dr Fowler said NHSE had accepted the recommendations and would work with local trusts to ensure they implemented its findings.

Health and social care secretary Wes Streeting, who met with the family before last year’s election, said: “There are no excuses for the tragic failings in the lead up to Yusuf’s death and I know first-hand how hard it has been for his family to live without the answers they deserve.

“It is now the responsibility of the NHS to implement the recommendations in this report.”