Cassian Curry
25 Apr 2022 · Coroner Abigail Combes · South Yorkshire (West District)
The coroner's concerns
1. lack of communication to parents about central line review plan
“[the deceased]'s parents were not told about the Consultant [name redacted] to review, reassess and pull back [the deceased]'s central line. Whilst this was not [the deceased]'s parents' responsibility, had they known about it they would have acted as a prompt for staff on a busy ward.”
2. staffing levels exceeding national requirements
“I heard evidence that the staffing levels on the Jessops Wing are over the national requirements. This therefore led to an assumption that staffing was not an issue or a factor which led to the failure to document [the deceased]'s requirement for review. However, there is a possibility that the number of staff placed an additional burden on the consultant (more junior staff means more questions) and that fewer staff may have offered greater consistency.”
3. inadequate regional support coordination for Jessops Unit
“I heard about the Jessops Unit having responsibility, not only for babies already in the unit but also for some of the sickest and most premature babies in the region. I did not hear any evidence of how the Jessops Unit access support from colleagues across the region. I heard evidence of trying to access colleagues to support the Jessops Unit directly and a buddy system but there are other neonatology consultants across the Region who could provide remote assistance potentially if encouraged to”
Responses
2022-0120-Response-from-Sheffield-Teaching-Hospital-NHS-Foundation-Trust.pdf ↗· Sheffield Teaching Hospitals NHS Foundation Trust
Stated action · 2022
“Utilising the support of parents in the shared care of babies We recognise the key role parents play in the shared care of babies in the neonatal unit. To ensure that there is a consistent approach to this involvement we are working with the South Yorkshire Neonatal Operational Development Network to deliver a network wide action plan for increased family involvement in neonatal care”
Stated action
“updated umbilical line insertion checklist has been amended and now includes a specific entry requirement for informing parents if the catheter is in a suboptimal position”
Stated action · March 2022
“In March 2022, we introduced a second consultant on duty at weekends for 5 hours e ach day to provide additional ward round capacity and a second point of contact for junior staff”
Stated action · next 2-3 years
“Increasing the number of Advanced Neonatal Nurse [name redacted] (ANNPs).”
Stated action · March 2023
“Converting some of our present 6 month junior doctor rotational posts to 12-18 month posts at Clinical Fellow level and 2-year International trainee posts”
Stated action · May-July 2022
“an audit of the new form will be conducted reviewing forms completed during May-July 2022 to assess the current levels of completion”