13.07.16
Parents and providers urged to work together to prevent child deaths
More children’s lives could be saved if parents and providers were encouraged to work together to spot the signs of deterioration, NHS Improvement said today.
Together with the royal colleges, NHS Improvement is launching a new Safer Systems Framework to stop parents being afraid to speak up because they fear ‘time-wasting’.
The framework comes following two reports into failings in care for child with heart problems at Bristol Royal Hospital for Children, which said that the hospital failed to respond adequately to parents’ concerns.
Dr Mike Durkin, NHS national director of patient safety, said: “Too often, parents with unwell children aren’t encouraged enough by medical staff to raise concerns about their child’s care or wellbeing, and worry about ‘potential time-wasting’ with any repeated concerns.
“But time and time again – and in some cases tragically too late – we see that some children could have received better care if healthcare providers worked with parents to understand and treat deterioration in health.”
There have also been a number of cases of children dying of sepsis after GPs and hospital staff failed to spot the signs, such as the death of one-year-old William Mead in 2014.
Today, NICE also published new guidelines on sepsis, saying that it should be medical staff’s first consideration when dealing with anyone with an infection.
The Safer Systems Framework is designed to go further to help health services identify other conditions.
It focuses on six core elements: patient safety culture, partnership with patients and families, recognising deterioration, responding to deterioration, open and consistent learning, and education and training.
Dr Durkin added: “This approach not only looks at early warning scores or symptom monitoring, but engages parents and families from admission to discharge, spots signs of deterioration and acts quickly, and embeds patient safety, openness and learning into the culture and system of organisations.”
Among patients of all ages, 26% of deaths are related to failures in clinical monitoring, and around 7% of patient safety incidents reported to the National Reporting and Learning System in 2015 as causing death or severe harm relate to a failure to recognise or act on deterioration.
Joanna Hughes of charity Mother’s Instinct, which helped develop the framework, said: “I and sadly many others like me who have lost a child unnecessarily have fallen victim to early warning 'scores' being used inappropriately or incorrectly to reassure both healthcare professionals and parents, when in fact a whole early warning 'system' approach, particularly one that empowers parents to feel able to continually speak up about their concerns, and that recognises 'parental concern' as an automatic reason to escalate would likely have saved us such extreme heartache.”
Fiona Smith, professional lead for children and young people’s nursing at the Royal College of Nursing, added: “When children are ill, it isn’t just about recognising signs. This framework shows how important it is to look at the whole care system rather than just one piece of the jigsaw.
“There are many factors involved in delivering the best outcome for a child, from the patient safety culture of the hospital to the way health care teams work together, and this brings all strands together in one cohesive way of working.
“The framework also recognises the need for parents to be treated as partners rather than bystanders in care. Parents can spot often small changes that others may miss and they should quite rightly play a key role in the care of their child too.”
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