Service Review. RCPCH Invited Reviews Programme

Transcription

1 RCPCH Invited Reviews Programme Service Review June 2016 Board Version- Patient identifiable content redacted Review of neonatal and paediatric services in Walsall Healthcare NHS Trust February 2016

2 RCPCH Invited Reviews Programme February Royal College of Paediatrics and Child Health Published by: Royal College of Paediatrics and Child Health 5-11 Theobalds Road London WC1X 8SH Tel: Web: The Royal College of Paediatrics and Child Health (RCPCH) is a registered charity in England and Wales ( ) and in Scotland (SC038299) Invited.reviews@rcpch.ac.uk Page 2 of 43

3 Contents Executive Summary 3 1 Introduction 4 2 Terms of Reference 4 3 Background and context 7 4 The Review process 11 5 Findings Paediatric Review 12 Casenote Review (patient identifiable 5.1 data redacted) Incident Review, complaints and DoC Medical Staffing and workload Nurse staffing Training and Supervision Compliance with Standards 18 6 Findings the Perinatal Mortality review 21 7 Summary and Recommendations 29 Appendix 1 The Review Team 32 Appendix 2 Information provided to the review team 33 Appendix 3 Contributors to the review 33 Appendix 4 Standards and reference documents 34 Appendix 5 List of abbreviations 35 Appendix 6 Casenote summaries- (redacted for Board) 36 Invited.reviews@rcpch.ac.uk Page 3 of 43

4 Executive Summary Walsall Healthcare NHS Trust invited the RCPCH to provide an external review of a number of historical paediatric cases, together with an opinion on the operation of the neonatal unit This was to provide the Trust with an opportunity to address once and for all a number of issues and concerns that had continued to be raised by a whistleblower, as well as issues cited by CQC, and offer a definitive opinion and recommendations for a way forward. The terms of reference were quite specific, looking at the management of paediatric complaints and operation of the neonatal unit, but although these have been met, the Review team extended the scope in order to address more systemic issues around medical staffing, and the pathways through ED. Overall the Review team found an extremely busy unit with a number of serious concerns although these were starting to be addressed. The medical staffing for the neonatal unit was insufficient both in numbers and expertise, particularly given additional pressure due to recent local reconfigurations. Staffing was being strengthened by a forthcoming lead neonatologist appointment and a 0.5 WTE tertiary part time neonatologist cover but it will be some months and require some investment before the service is robust. There is an inappropriate reliance on Advanced Nurse Practitioners to manage the neonatal unit and although across both neonates and paediatrics the Review team found excellent nursing leadership, recent restructuring has left the nursing rotas with insufficient experienced staff nurses. Governance arrangements particularly around complaints, investigations and RCAs did not appear to be sufficiently robust or thorough to reassure the Review team that lessons had been learned and changes implemented as a result. If approached effectively, complaints and incidents can offer an excellent opportunity for staff development and team building which itself restores the confidence and builds capability in staff, We found that the staff were looking to the future expansion of the LNU, relocation of the PAU as the solution to their problems but we would recommend a number of immediate steps be instigated which are set out in chapter seven of the report. The new consultant neonatologist must be supported to revitalise the neonatal unit in terms of practice, skills and competencies. The pressure on the paediatric unit must be addressed now through development of better arrangements to reduce attendance and increase acute care out of hospital as well as investment in appropriate nurse staffing. The CQC has recently announced that the Trust is in Special Measures so whilst we recognise the impact this will have on management attention we hope that our report will provide a realistic way forward to ensure that the children and families of Walsall can have confidence in their local services. Invited.reviews@rcpch.ac.uk Page 4 of 43

5 1 Introduction 1.1 RCPCH was approached in September 2015 by Dr Louise Holland, Associate Medical Director, to conduct an invited review of paediatric and neonatal services at Walsall Manor Hospital, Walsall Healthcare NHS Trust. This report provides an independent critique of the service against agreed terms of reference, based upon information provided to the reviewers and evidence gathered through a two-day site visit and subsequent telephone conversations with other members of staff. 1.2 The review report takes into account adherence to published policy, guidance and standards developed by RCPCH, other professional bodies and the government, where these are available, together with the objective workforce and service design experience of the review team, drawing on and supported by the RCPCH. It is the property of Walsall Healthcare NHS Trust through the Medical Director. It remains confidential between the Trust and those appointed by the RCPCH to produce the report unless there are serious concerns that justify RCPCH sharing it directly with regulatory authorities. However RCPCH encourages wider dissemination of this report by the Trust amongst those involved in the service. RCPCH will not itself publish or comment on review reports without the agreement of the review client. 2 Terms of reference The review comprised two elements and the following terms of reference were agreed: The Paediatric Incident Review 2.1 To review a series of paediatric incidents and claims to identify whether there are wider themes or issues relating to the care provided and/or the way the Trust responds to such incidents.- To provide external expert oversight review of seven paediatric cases five raised through the Trust Development Authority whistleblowing process and two included by the Trust with particular reference to any relationship between each of the cases or any wider pattern. To review the Trust s paediatric complaints, serious incidents and claims since April 2014 for themes and trends with particular (but not exclusive) reference to the point above. To advise the Trust board on whether the cases and/or recent incidents raise themes or issues relating to the quality of the Trust s paediatric service that need to be addressed; To advise the Trust board on the organisation s handling of and response to these cases. Duty of Candour did not become a formal requirement until November 2014; but the review should advise the board if the principles were upheld and all reasonable steps in place at that time were followed. Invited.reviews@rcpch.ac.uk Page 5 of 43

6 The Perinatal Mortality Review 2.2 To review the perinatal services and assure the Trust Board they are fit for purpose and ensure all learning points implemented following the Perinatal Institute report (June 15): Review of Perinatal and Infant Deaths and Maternity Care in Walsall. In addition, a review of a neonatal death was requested, where the Trust was criticised by the Coroner. The review team was asked: To review the findings of the Perinatal Institute report into neonatal and infant mortality and ensure all actions have been implemented. To review the Inquest case in which the Trust was criticised and advise the Board on the quality of care provided by the neonatal services. To review the clinical leadership with the neonatal services, particularly with reference to neonatal resuscitation including airway management. To assess the skill mix of the consultant paediatricians advising on their ability to provide neonatal cover. To assess the Trust s response to stillbirth, perinatal deaths and all poor neonatal outcomes and ensure the incident reporting and RCA processes are robust and fit for purpose. To advise the Board on the overall quality of the neonatal services. 2.3 During the site visit which took place between 26 and 27 November, it came to light that the inquest case as referenced in the ToR (and one of the seven cases) has proceeded to litigation. The Review team referred to the RCPCH Guide to Invited Reviews which states the following: The College will not take on cases where: - the requirement is for a clinical opinion to support a court case (medico-legal); - the request is simply for a review of case notes without visit or service context; - the expected scope includes behavioural, misconduct, bullying, harassment or possible mental health concerns; - the doctor is a trainee (these should be referred to the relevant Deanery); - the GMC Fitness to Practise process is underway; - there are disputes regarding contracts or terms of service; - the Police or Counter Fraud service are involved; or - individuals approach the College themselves without Medical Director agreement. In these situations the client will be advised to discuss with NCAS the circumstances of the case and/or where appropriate seek a doctor willing to undertake private work or commercial firms who source medico-legal expertise. If any of the issues listed in 4.5 come to light during an IR, the review should be completed in relation to its original remit unless advised to the contrary in order to avoid prejudicing other investigations by a public authority or regulator, but the reviewers cannot Invited.reviews@rcpch.ac.uk Page 6 of 43

7 investigate or suggest solutions for any of the above. Clear scope boundaries should be agreed before further work takes place in order to avoid prejudicing other investigations, which should be undertaken if required under existing internal or NHS mechanisms. 2.4 The Review team were therefore unable to probe this case in depth within the review, and as a consequence have not addressed the second bullet point of the perinatal mortality section of the Terms of Reference. 3 Background and Context Demographic information 3.1 Child Health Profiles for Walsall indicate that the health and wellbeing of children in Walsall is generally poorer than the English average with: Infant mortality and child mortality rates higher than the English average. Levels of poverty higher than the English average, with 29.2% of children aged less than 16 years living in poverty. Rates of childhood obesity higher than the English average, with 11.5% of children aged 4-5 years and 23.0% of children aged years classified as obese. A higher percentage of births to teenage girls compared with English and European averages Emergency Department (ED) attendance rates for children under four years of age and hospital admission rates for injuries in young people are lower than the England average 2. Organisational structure and history 3.3 Walsall Healthcare NHS Trust is the only provider of NHS acute care in Walsall, providing inpatient and outpatient services, as well as a wide range of services in the community to around 260,000 people in Walsall and the surrounding areas. Despite the proximity of Walsall to Birmingham and other Midlands hospitals, the review team were informed by the management team that the local population were apparently reluctant to attend elsewhere. 3.4 Paediatric and neonatal services sit across two care groups within the Women s, Children s & Clinical Support Division; acute and community paediatric services within the Children s and Family Services Care Group, alongside public health services, such as health visiting and school nursing. Neonatal services sit within the Women s Services Care Group, alongside maternity Invited.reviews@rcpch.ac.uk Page 7 of 43

8 3.5 During the site visit the Review team were informed of a history of concerns which had been raised by a former clinician of the service (via the Trust Development Authority whistleblowing process) regarding paediatric service provision. The Review team were provided with a list of the most recent complaints, comprising mainly historic cases, which were received by the Trust a few months prior to the site visit. The Trust reported that they have been informed by partners that they have acted appropriately and did everything required, however they require independent view from the RCPCH to confirm this. 3.6 In October 2015, Walsall Healthcare NHS Trust received a Care Quality Commission (CQC) warning notice. This highlighted a lack of qualified paediatric nurses or a paediatric consultant based in the Emergency Department (ED), increasing the risk that children may be assessed by inadequately qualified nurses, delaying access to appropriate specialist treatment. Since this notice the Trust has put in place an interim solution for a Band 7 Nurse and two band 6 sisters from the children s department to work in ED covering 4 long clinical shifts per week and two Band 6 children s nurses already employed by ED. In addition, a member of staff from the paediatric unit attends ED when a child is in resuscitation; ED team are still working on night management. There are also longer term estate plans to move the Paediatric Assessment Unit (PAU) next to the ED, with all children being diverted into the PAU. The review team were also informed by the clinical leadership team that the Trust have not received any formal paediatric complaints about ED, although there had been incidents reported relating to children. 3.7 The Perinatal Institute was commissioned by Walsall Borough Council to investigate the underlying causes of high perinatal mortality in the Walsall population compared with regional and national averages. The high rates of perinatal mortality were identified as a priority in the Walsall Joint Strategic Needs Assessment The unit has come under increased pressure of recent years, with an increase in births due to the closure of two other maternity units in the region (Stafford and Sandwell). The current birth rate is around 4,800 births per year, with approximately 3,500 of these births from the Walsall area. The Review team was told that the service plans to cap the number of maternity admissions at 5,000. Infrastructure 3.10 The site underwent a 170 million redevelopment in Refurbishment of Ward 21, the paediatric inpatient ward, and the paediatric assessment unit (PAU), formed part of the refurbishment, but the neonatal unit has not yet been refurbished The paediatric service is integrated across acute and community sectors. The medical team comprises 14 WTE (1.0 WTE vacant) acute / neonatal and community consultant paediatricians (Tier 3), together with five specialty doctors, two associate specialists, 1 MTI and four Tier 2 training posts. There are ten Tier 1 posts. There is a 3 Invited.reviews@rcpch.ac.uk Page 8 of 43

9 supernumerary FY1. Staffing levels have improved in recent years, with 1 in 8.5 on-call system for consultants, and a Consultant of the Week system in place The community nursing team consists of children s nurses, a School Nurse, one WellChild discharge Nurse and Assistant Practitioners. In addition, the service employs specialist children s epilepsy, asthma, allergy and diabetes nurses. A seven day children s community nursing service is provided, operating 12 hours per day during the week and between 9am and 5pm at weekends, with 24 hour cover for end of life care. Some limited acute care is provided, but there are plans to expand the Hospital at Home service with redevelopment of the PAU pathways. Ward 21 - Inpatient Unit 3.13 The unit has 21 beds comprising two, 4-bed bays with ensuite, and 13 cubicles. There is one room (Rm 19) equipped for HDU patients, however, the unit is not commissioned for HDU provision. There have been around 10,000 inpatients per year for the past three years, and the emergency department sees around 17,000 children a year including 5,000 referred to the GP/walk-In centre and 2,000referred to PAU. The remainder are seen by ED alone The unit provides a play room, a sensory room and an adolescent room, and one self-contained room for parents. There is also a small outdoor area which can be accessed directly from the ward The unit has 7-day play therapist cover; a paediatric asthma service (funded by the CCG following initial seed funding from the third sector of 0.6 WTE); and a full-time epilepsy nurse and two diabetes nurses at Band 6/7. There is a constipation specialist nurse within the CCN team 3.16 Day surgery/case patients are usually admitted to the Inpatient Unit, but occasionally patients requiring only brief stays are admitted to the PAU when the ward is busy. Senior Nurses usually meet at 7.30am, before the medical round, to discuss beds, breaches of waiting times and possible discharges. In addition, day case lists were halved from 6 to 3 cases, during a six week period over the winter to prevent cancellations. Day surgery is planned with dedicated children s lists, except for trauma, when children are placed first on an adult list. Paediatric Assessment Unit (PAU) 3.17 The PAU is a six bed unit (2 cubicles and a 4 bed bay) providing a 24/7 service, with a resuscitation room and two large treatment rooms. The review team were informed by staff that the unit sees around 400 to 800 children per month. Winter is busy with 100 more patients seen in November 2015 than in 2014, without needing to use escalation procedures to divert children elsewhere. Escalation has been used to close the unit for Invited.reviews@rcpch.ac.uk Page 9 of 43

10 short periods until children can either be admitted to the ward or discharged. In this situation a Tier 2 doctor from PAU will work in the ED, assessing children and either referring or treating and discharging them Children and young people can be admitted to the PAU for between four and eight hours, before being transferred to the inpatient unit. Referrals are received from local GPs, ED, midwives, health visitors and the Walk in Centre. In addition, a number of children with complex and long term conditions have direct access to the hospital via the PAU. Children requiring review following discharge from PAU or the ward are invited back to PAU in the mornings to avoid busy periods. When Ward 21 is busy, day cases are admitted to PAU to prevent cancellations, and staff normally report this as an incident to ensure that management are aware of this practice. The CLIPS report for April 2014 to October 2015 reports four such incidents across children s services relating to operative procedures during this period There are plans in place to redevelop the emergency department, with the PAU collocated, so that all children will be directed to PAU. Staff reported that this will provide a safer, more streamlined pathway through the service, which needs to work differently. Neonatal Unit (NNU) 3.20 The unit has been designated as a Local Neonatal Unit (LNU) under BAPM guidelines. It is part of the Shropshire, Staffordshire, and Black Country neonatal network, with the nearest network Level 3 Unit at the Royal Wolverhampton NHS Trust It has funding for 15 cots, comprising 2 ITU, 2 HDU and 11 Special Care. However the unit is frequently operating at 18 cots, with 4 cots in the three bed HDU area and 5 cots in the intensive care room. The ITU room is located opposite the nurses station, with nurses based at this station; however there is no central patient monitoring in the ITU room and although the nurses are required to remain in the room, it is acknowledged at times, that they need to leave the room to undertake tasks such as drug preparation, answer the telephone etc. There is direct access from the labour suite to the NNU, with daily meetings between the teams to communicate about expected deliveries and discuss cot availability There are local plans to open to 20 cots in the future, increasing the number of high dependency cots, which is where the demand lies. The Review team was shown plans for the refurbished NNU, with a much larger footprint for this service but there is no clear date for completion of the work. There is currently no provision on the unit for transitional care, which is currently catered for in special care and the post-natal ward. Invited.reviews@rcpch.ac.uk Page 10 of 43

11 4 The Review Process 4.1 The Review team (see Appendix 1) were provided with pre-reading detailed in Appendix 2 during the week prior to the site visit in November A tour of the facilities and face to face interviews took place with those listed at Appendix 3 on 26 and 27 November 2015 on site at Walsall Manor Hospital, Moat Rd, Walsall WS2 9PS. Additional telephone interviews took place between Carol Williams and the nursing staff between 18 th and 24 th December, due to unplanned unavailability on the second day of the review. 4.3 Some additional documentation was requested during the site visit, some of this was received during the visit and some was provided at a later date. 4.4 Meetings were held with individuals or groups who were asked questions based on the ToRs, and given the opportunity to tell the review team anything else they thought would be useful for them to know at the time. All interviewees were provided with contact details (telephone and address) should they wish to add anything at a later date. Notes were taken at the meetings. These have not been transcribed but have been used alongside the documentation provided, to inform this report. 4.5 A feedback meeting was held with the senior management, including the Clinical Director, Medical Director and Chief Executive on Friday 27 November. The review team informed those at the meeting that due to a delay in receiving case notes, and in the absence of all documentation they were only in a position to provide some general feedback. 4.6 The Review team also passed on their thanks to all participants for their hospitality and engagement with the process, their openness, and their time. Invited.reviews@rcpch.ac.uk Page 11 of 43

12 5 Findings Paediatric Review 5.1 Case note Review The Review team were asked to provide external oversight of seven paediatric cases and note the relationship between the cases or any wider pattern. These cases were historical, dating from 2003 and are analysed in a confidential appendix and summarised as follows: The summary and Appendix 6 have been redacted as there is patient identifiable information. One case was not reviewed (see section ) These six reviewed cases covered a diverse range of issues and historical periods. There was no one specific theme or individual emerging as a problem, so the team conducted a full review of the service against professional workforce and service standards, seeking input from staff alongside a study of relevant documentation. The RCPCH consider this would provide a meaningful and current report and recommendations that could engage and encourage the staff. 5.2 Incident review, complaints and Duty of Candour The review team were asked to review the Trust s paediatric complaints since April 2014 and were provided with a basic summary of the complaints received and some examples of incidents and complaints that had resulted in a change in practice or equipment. In addition, information was provided relating to retraining, competence assessment and provision of individual support in practice. Of the total complaints reviewed, 11 were related to the PAU and 3 were related to Ward 21.

13 5.2.2 The number of formal complaints was felt not to be excessive given the number of patients to the service; however five of the complaints were about direct clinical care which is unusual for paediatrics. This included complaints related to lack of interpreter provision, the skill of medical staff and staff, and one complaint was related to the staff attitudes Informal complaints are recorded at a rate of 4-8 per month which is higher than many units experience. These highlight issues around staff attitude, communication and care issues, although the majority of informal complaints relate to appointments, delays in being seen and not being told of results. Senior staff felt that these complaints occurred as a result of high workloads resulting in pressure on staff, which may well be the case, and rather than attempts to examine these incidents in detail, the Review team conducted a wider review of workload, activity and compliance with standards to identify any core ongoing issues with the team and the service which could be triggering complaints A specific ENT complaint was reviewed (Specific clinical details redacted). The response letter from the Trust is brief and does not address all the complaints, although this may have been done verbally as Trust representatives met with the parents. The Trust stated that they intended to address the staff training issues but in the absence of any further information, the Review team s opinion is that the response to this genuine complaint was not adequate The Review team was confident that the unit has a low threshold for serious incident reporting, hearing that there had been cases referred which the CCG felt did not constitute a serious incident. Clinical staff reported that incidents were discussed at meetings and feedback was received when an incident was reported, and the Review team looked at some of these during the visit, but were unable to find any further evidence of actions following serious incidents, escalations to the ombudsman or lessons learned. There was no evidence that informal complaints were routinely followed up and learning from these resulted in change to practice The Trust follows a Root Cause Analysis (RCA) processes, including for cases 4&5. During the site visit the review team heard from staff that they felt RCAs could be strengthened with oversight by a consultant from another department within the Trust. One RCA (details redacted for patient identifiable information) has a number of serious omissions relating to obstetric practice, the timings of alert calls and the arrangements for network support. The Review team heard that there have also been some issues with grading of incidents, but the Trust has apparently implemented training to support this, and from January 2016 the Trust is moving to incidents being investigated by other departments The governance structure within the trust is not integrated, with patient experience, complaints and all other governance matters being divided between three directors. There is a complaints monitoring group, which has been working to improve feedback to Invited.reviews@rcpch.ac.uk Page 13 of 43

14 complainants, with a letter from the CEO within 30 days. Divisional governance meetings review local issues but we did not see evidence of a cross-divisional Quality or Clinical Governance group which reports to the Trust Board. Such a group would usually be chaired by the Director of Operations, Director of Nursing or Medical Director who takes overall responsibility for clinical governance issues. Duty of candour Following discussion with a representative from the Clinical Governance team the reviewers were reassured that there are no current problems in relation to duty of candour at the service. Of the seven specific cases for review, it was noted that all families were contacted however two did refuse. Patient expectation and satisfaction Despite the relatively high level of complaints, the Friends and Family test, showed over 90 per cent of respondents likely to recommend the service, and the CQC patient survey published in July 2015 showed that results were about the same as equivalent hospitals. Some staff explained that they felt that expectations of the local population were low and the friends and family test was relatively static for the Trust. 5.3 Medical staffing and workload As stated previously, there are 14 WTE acute and community consultant paediatricians (1.0 WTE vacant). There are 8.5 WTEs on the acute on call rota, 4.0 WTE covering the NNU during the day and 5.0 WTE covering the children s ward and a Consultant of the Week system in place for both reas. The on-call workload was thought to be very high, with coverage of both the paediatric unit and NNU. The Review team noted concerns relating to paediatric consultants covering the neonatal service, without the necessary knowledge and experience. The unit has attempted to address this by establishing a rota where some consultants do not cover the neonatal unit but serious concerns remain - see paragraph 6.5 All 8.5 WTE cover the NNU during on call The Review team found the consultant team to be very committed, mutually supportive and dedicated, exhibiting good teamwork and willing to support the junior members of the medical team. The job plans for most of the consultants were seen and they appear satisfactory and workable. No problems with job plans were mentioned in our interviews with the consultants, but they were concerned about the intensity of the out-ofhours unscheduled workload, which will not be reflected in job plans There was no documentation supplied about consultant appraisals, but given that GMC revalidation rules make this obligatory on an annual basis, the Review team assume that these happen There are ten Tier 1 posts and four Tier 2 training posts, plus 5 specialty doctors, 1 MTI and 2 associate specialists plus 1 supernumerary FY1; staffing levels have improved in Invited.reviews@rcpch.ac.uk Page 14 of 43

15 recent years. The PAU is covered by a Tier 1 and a Tier 2 doctor during the day, with one Tier 1 doctor for PAU, Ward 21 and the NNU in the evenings (7-9pm) and two Tier 2 and 2 tier 1 doctors at night, two covering the NNU and the other two covering ED, the Ward and PAU. An 8am medical round aims to encourage early discharge of children from PAU and Ward 21 to accommodate day case admissions. In addition, a consultant works three sessions each week between 1pm and 5pm to cover the busy period. The review team noted concerns with the current shift system, with only one middle-grade staff member covering both the paediatric unit and NNU from 5am until 9am. This should not have a major effect on compliance with the Facing the Future standard as this is normally a quiet period in ED and any child admitted just after 5 am should normally get seen just after 9am at the latest, thus satisfying the 4 hour standard The evening gap when there is only one Tier 1 doctor between 7-9pm is more of a problem, as this is generally acknowledged to be a peak time for admissions. Recent difficulties recruiting to the Tier 2 rota has resulted in the recruitment of consultants covering the Tier 2 rota for 3.5 sessions per week between 5 and 9pm. Again this should not affect compliance with standards, but is nonetheless a problem. Using a consultant doing a resident evening session does not necessarily alleviate this problem, as the need at that time is more for a more junior member of the team, clerking new patients and doing practical tasks. It is not acceptable for consultants to take on the workload of a Tier 1 doctor on a regular and predictable basis A partial solution, already being considered by the Trust, might be to make more use of physician s assistants and advanced paediatric nurse practitioners at these times. These practitioners could take on the routine workload in the absence of sufficient Tier 1 doctors, with the consultants spending their time more appropriately, making decisions, liaising with colleagues, and speaking to parents Child protection referrals are handled by the Community paediatricians, but they only work 9-5 weekdays so all acute concerns out of hours as well as any trauma cases are seen by the acute team, which further impinges on their capacity to manage PAU and emergency attendance as an examination can take a doctor away from other activity for at least 2 hours. This had been flagged as a concern within the Trust. 5.4 Nurse staffing In October 2015, the CQC highlighted the lack of suitably trained children s nurses in the ED in a warning notice to the Trust. This has been addressed by moving the Ward 21 Band 7 Sister to the ED to address systems and processes and support training of staff. In addition, two band 6 sisters (4 shifts per week) have been rotated to the ED to add to the existing complement of two band 6s, with the aim of providing a children s nurse throughout the 24 hour period. This will provide one children s nurse per shift in the ED, except during holiday periods. This has depleted ward staffing, with the Matron and PAU Sister covering the Ward Sister, and Bank Nurses used to backfill the staff nurse shifts. Invited.reviews@rcpch.ac.uk Page 15 of 43

16 5.4.2 Nursing staff is based on separate rotas for PAU and Ward 21. There is usually one Band 6 rostered across the service to provide senior support to both areas throughout the 24 hour period. This is evident from the rotas provided, but this nurse is often one of the two nurses working on PAU, making it difficult for this person to provide direct supervision on the ward On the PAU, there are generally 2 registered children s nurses and one healthcare assistant, although it was reported that, at night a healthcare assistant might work between PAU and the ward. Nurses felt that staffing was adequate except during the late shift, when an extra nurse is required. A paper has been submitted to the Board in March/April 2015, but the outcome of this has not been agreed to date. Staffing for the proposed redevelopment of PAU was reported to be under discussion with the Emergency Department team and commissioners. This is likely to include the children s nurses currently employed in the ED Senior nurses have looked at models of advanced practice in relation to PAU and had visited Liverpool. However, a lack of funding has prevented development of a similar model for the PAU in Walsall. It is likely that medical posts will be more difficult to recruit to in the future and advanced nurse practitioners who can work on the middle grade rota can prove very useful and create stability in the workforce. However, it takes around two to three years to train an ANP to be able to work independently, requiring forward planning and review of roles of the existing workforce with appropriate skills Ward 21 bed occupancy varies between % in the winter months and 60-70% in the summer, with an average length of stay of 1.4 days. There are generally four registered children s nurses with additional healthcare assistants and play specialists seven days a week, to cover the 21 beds. The nurse in charge will have a patient caseload. Staffing is adjusted to meet this demand by allowing nurses less holiday between October and March than April to September and using bank or agency nurses to fill gaps. In addition, flexible contracts include annualised hours, with fewer hours worked in the summer and more in the winter months. This was reported to generally work well to ensure sufficient nurses on duty, with the additional flexibility achieved by moving nurses to areas of highest need. However, the review team heard that adjusting the nurse staffing rota and moving staff around was happening almost daily during the winter, relying on the goodwill of ward nurses which is unsustainable over long periods The review team were told that Agency nurses have only been required over the last two years. There are a small group of regular agency staff who have completed local competencies and who are booked in advance to fill known gaps in the rota, but this did not meet all available slots Staff reported the nursing staff to be fantastic, but there were too few of them and with the loss of some senior nurses on NNU, there were a high proportion of junior nurses. Invited.reviews@rcpch.ac.uk Page 16 of 43

17 There was widespread recognition that nursing numbers do not meet the RCN 2013 staffing standards, despite establishment increases over the last four years. Daily RAG rating against these standards regularly identifies the ward as red or amber, with PAU now green. The CLIPs Report for April 2014 to October 2015 indicates that Ward 21 reports 58% of all staffing related incidents within the hospital and 65% of all medication errors, but it was suggested that this is because of a good reporting culture. These figures suggest that staffing is regularly insufficient. There is a growing body of evidence to suggest a link between poor staffing and patient outcomes 4, 5 which would indicate the need for an urgent review of nursing numbers To assist with more accurate assessment of workload, the senior nursing team are looking at SCAMP (Scottish Children s Acuity Measurement in Paediatric Settings) to assess the dependency of children and workload on Ward 21. There is a Paediatric Early Warning System (PEWS) on PAU and ward 21, used to identify the sickest children who require more nursing input The senior children s nurses should be commended for implementing a range of flexible staffing options to maximise nurse staffing when activity is high. Despite this, they acknowledged that the service does not yet meet the RCN Staffing Standards. It is recommended that the unit reviews the workforce further to take note of the requirements of the core and service related standards, which recommend a supernumerary shift supervisor and a minimum ratio of 70:30 registered to unregistered staff. In addition, the use of PANPs in PAU would assist with throughput of children, especially during periods when there are few medical staff and in the future when it is expected there will be less medical staff available to fill posts. 5.5 Training and supervision The Review team noted a mixture of training and non-training grade posts, but that they all received teaching, supervision and appraisal. There was good evidence of active teaching and training for both medical students and postgraduates, and the Review team was supplied with a full schedule of teaching sessions, although no evidence that these actually happened. They schedule monthly perinatal and radiology meetings, and scenario training sessions; lunchtime teaching sessions twice a week aimed at different level trainees; a weekly grand round which once a month becomes an audit meeting. The Review team could not find evidence of attendance at regular mandatory resuscitation and safeguarding updates, but did not ask about this specifically The 2015 trainee survey for Walsall paediatrics shows ratings given by trainees that are mostly in the middle, with no areas that are particularly good or bad, and no different to national averages, although paediatrics is better than some other specialties in Walsall 4 RCN (2010) RCN policy position: evidence-based nurse staffing levels 5 Wilson S, Bremner A & Hauck Y (2011) The effect of nurse staffing on clinical outcomes of children in hospital: a systematic review. International Journal of Evidence Based Healthcare 9(2); Invited.reviews@rcpch.ac.uk Page 17 of 43

18 5.5.3 Trainees generally reported a good experience with consultant support available throughout the 24 hour period, but they had some concerns related to the rota gaps, including those highlighted in section and and continuity of experience on the neonatal unit. At weekends, when ANNPs are not available for the post natal wards (there is an ANNP on NNU), the medical team are covering all NIPE assessments, which increases the workload of trainees. Overall, the workload is tiring, includes a high number of weekends, fixed leave and occasionally study leave undertaken in time off, which was described as draining. There are also concerns egarding confusion between the neonatal and paediatric crash bleeps, resulting in calls being directed to the wrong person Structures in place for nurse training appear good, with rostered mandatory training, monitoring of attendance and an annual training needs analysis to plan education each year. The review team were informed that there was good access to specialist training, with support with both time and funding in many cases. Part time nurses attending training often do this as additional paid hours. The consultant paediatrician (special interest in allergy) provides paediatric allergy training and the Paediatric Allergy Nurse Specialist and CCNs provide training in other organisations and funds raised from this are used to support nurse education All nurses were reported to be up to date with resuscitation training, with all HCAs trained in basic paediatric life support, all Band 5s have completed PILS and all Band 6 and 7 nurses are EPLS 6 trained with the paediatric Matron being an APLS 7 instructor. Resuscitation training incorporates both planned and unplanned simulation events, involving all relevant members of the clinical teams. The review team were told that these simulations covered a wide range of scenarios and age group. Staff were reported to provide positive feedback on these and receive feedback on performance The Review team were told that nursing support on Ward 21 for HDU patients was good, with a perception of more nurses having the required skills more recently. We were informed that there were around eight nurses who had undertaken the HDU Course The service has invested in 5.8 WTE Clinical Support Workers who have been trained by the CAMHS Service to address the needs of children with mental health problems on the ward. In addition, 80% of nurses were reported to be trained to recognise the risks of self-harm through STORM training. This was reported to have provided a more responsive service focused on early assessment, discharge and care at home. 6 Emergency Paediatric Life Support 7 Advanced Paediatric Life Support Invited.reviews@rcpch.ac.uk Page 18 of 43

19 5.6 Compliance with Standards Overall the paediatric unit appears to be meeting the 2011 RCPCH Facing the Future Acute Standards, and had audited two of these standards in 2015 (see Paeds audit 15 ). They found: All admissions to be seen by middle-grade or consultant within 4 hours: 83% compliant Consultant to lead at least one medical handover every 24 hours: 100% compliant. This is sub-optimal but no different to what might be found in many busy units In 2015 the RCPCH published Facing the Future Together for Child Health which examines the urgent pathway of care and defines eleven standards aimed at reducing pressure on acute services by increasing community and primary care based services. Some of these recommendations are already being implemented by the Trust, and specific standards which affect reduction of overall pressure on the PAU include Standard 1- GPs seeing or treating children with unscheduled care needs have access to immediate telephone advice from a consultant paediatrician. There was reported to be an advice line manned 9-5pm by the associate specialist, at 24/7 consultant is available for advice. Standard 2 - Running a consultant-led rapid-access service to enable any child referred for this service to be seen within 24 hours of the referral being made. Although in effect this is the nature of the PAU, there is currently no booking system resulting in the unit being overwhelmed at times. The weekly rapid access clinic is a stage towards this referrals are seen by a middle grade doctor or above. Referrals are triaged by a senior nurse or middle grade, some are booked for a review or appointment in rapid access clinic, and this could be further developed. All these might appear to increase consultant workload in the short term but would be worthwhile if attendances were decreased. Accident and Emergency Although outside the ToR, the issue of paediatric cover in ED was raised several times and the CQC warning notice was provided in advance of the site visit, so the Review team briefly examined the pathway of care for children using this department against the Intercollegiate standards 8. The threshold of 16,000 attendances suggests that appointing a lead paediatric ED consultant, with safeguarding and acute care responsibilities should be a priority. The individual currently nominated as the paediatric lead is also the Clinical Director but the role is too big to combine The ED has two designated cubicles for paediatrics; however there are occasions when adults will be placed into paediatric cubicles and vice versa. A GP-led urgent care 8 Standards for Children and Young People in Emergency Care Settings RCPCH 2012 Invited.reviews@rcpch.ac.uk Page 19 of 43

20 centre is co-located on site which has reduced the number of children seen in the department The review team noted plans to relocate the PAU alongside ED and that this was widely viewed as a positive development by paediatric consultants and middle grade doctors interviewed during the site visit. This would however reduce the flexibility in allocating medical and nursing staff when compared with the PAU being alongside the inpatient ward. Either way, there must be adequate staff to care for sick children in both areas. The review team also noted current measures to improve paediatric nursing cover in the ED, with nurses rotating from the ward to cover some shifts and a nurse from PAU attending paediatric cases in resuscitation Feedback from the ED medical team indicates that they have a good working relationship with the paediatric team. Paediatric consultant cover is seen as adequate, and support from the team excellent. The paediatric team have supported the department to introduce the Health Foundation s paediatric asthma bundle 9, with plans to introduce the paediatric sepsis bundle. Plans are also underway for the nursing staff to undertake the 'managing sick child' course. ED reported the main issue concerning the department relates to retrieval arrangements to the tertiary centre which puts considerable stress on the system. 9 Invited.reviews@rcpch.ac.uk Page 20 of 43

21 6 Findings - The Perinatal Mortality Review 6.1 The CCG commissioned the Perinatal Institute to investigate the underlying causes of high perinatal mortality in the Walsall population compared with regional and national averages. The report contains recommendations across maternity and neonatal services, with the following learning points specific to the neonatal service provision: Consultant Paediatrician with overall responsibility for the management of each neonatal case needs to ensure that teams understand the individual plans of care Neonatal leadership needs to be clearly defined Communication and co operation with adjacent Level 3 unit (NICU) needs to be enhanced. This should include keeping a record all network communications to ensure quality control A clear guideline for the transfer of neonates needs to be formulated in conjunction with the Neonatal Network Resuscitation and medication management needs to be regularly audited and training needs reviewed Neonatal weight needs to be assessed using customised birthweight centiles in continuum with antenatal assessment, to avoid confusion and ensure that SGA/FGR neonates are recognised and cared for on an appropriate postnatal pathway. Actions following Perinatal Review 6.2 The review team were asked to investigate whether all actions outlined in the Perinatal Institute report in relation to neonatal and infant deaths had taken place. The review team were provided with a joint stakeholder action plan from the Trust which set out key actions the Trust is undertaking in response to the recommendations. In addition to this information, the review team were able to make enquiries during the onsite visit, as well as request additional information. 6.3 The review team was satisfied that most of these actions were either commenced or completed (see Table 1). Table 1: Summary of recommendations and actions from the joint stakeholder action plan Action(s) Findings Recommendation: Consultant paediatrician needs to have overall responsibility for the management of each neonatal case ensuring teams understand individual plans of care Consultant paediatrician s presence mandatory for deliveries at <28 weeks - to be added to local clinical guideline. The Review team were satisfied that this this is now in place.

22 Neonatal department is actively engaging with Supporting the sick neonates programme. Simulation training to be commenced with the service. The Review team were not satisfied that there is currently sufficient engagement from the medical team, with a need for multidisciplinary scenario training. The Review team were reassured by staff that there are plans in place to develop this in 2016, with nurses confident that the Neonatal Lead will contribute to this as they develop in post. Peer Review Training - Data is discussed at governance meetings, including action plans and information is fed back to colleagues and other staff via the board in the education office. Peer review to discuss cases is also held quarterly, Recommendation: Ensure adherence to protocol re transfer of preterm infants. The neonatal service is to adhere to local and Network guidance in relation to the transfer of the preterm Neonate. 1) all babies <28 weeks are transferred out either in-utero or ex-utero. 2) if a cot is not available within the network, it is escalated to consultant obstetricians and neonatologists both here and at the tertiary unit Staff to incident report when compliance not achieved. Staff reported that women are transferred out unless there is no bed available. The Review team recommend an audit to ensure that the service is adhering to the 28- week policy. The Review team noted that Birmingham Children s Hospital plans to take over the cot bureau in It is hoped that this will facilitate speedier identification of maternal beds and neonatal cots. Recommendation: Enhanced communication and cooperation with level 3 (NICU): interactions and outcomes of transfer requests should be recorded to allow audit and review. The neonatal service is to adhere to local and Network guidance in relation to the transfer of the preterm Neonate. Staff to incident report when compliance not achieved. Neonatal peer review meetings on a quarterly basis The Review team were informed of a project being coordinated through the obstetrics and neonatal network where women with babies with PPROM in Walsall <28 weeks will be transferred directly to New Cross. In/when they reach 28 weeks they will be transferred back to local service. The review team strongly recommended an audit be undertaken of this project. The Review team understand that a pathway for neonatal and obstetric services has been developed.