Summary Management of chronic asthma in children aged 16 years and under - Independent report by the Healthcare Safety Investigation Branch ...
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
WWW.HSIB.ORG.UK Summary Management of chronic asthma in children aged 16 years and under Independent report by the Healthcare Safety Investigation Branch I2019/010 May 2021
Providing feedback and
comment on HSIB reports
At the Healthcare Safety Investigation This document, or parts of it, can be
Branch (HSIB) we welcome feedback copied without specific permission
on our investigation reports. The providing that the source is duly
best way to share your views and acknowledged, the material is
comments is to email us at reproduced accurately, and it is not
enquiries@hsib.org.uk or complete used in a derogatory manner or in a
our online feedback form at misleading context.
www.hsib.org.uk/tell-us-what-you-think.
We aim to provide a response to all
correspondence within five working days.
© Healthcare Safety Investigation Branch copyright 2021.
2
About HSIB
We conduct independent patients. The safety recommendations
investigations of patient safety we make aim to improve healthcare
concerns in NHS-funded care across systems and processes, to reduce risk
England. Most harm in healthcare and improve safety.
results from problems within
the systems and processes that We work closely with patients, families
determine how care is delivered. and healthcare staff affected by
Our investigations identify the patient safety incidents, and we never
contributory factors that have led attribute blame or liability.
to harm or the potential for harm to
Considerations in light of coronavirus (COVID-19)
We have adapted some of our national healthcare system across England. For
investigations, reports and processes this report, the way we engaged with
to reflect the impact that COVID-19 has staff and families was revised.
had on our organisation as well as the
A note of acknowledgement
We would like to thank the family healthcare staff who engaged with the
of the child whose experience is investigation for their openness and
documented in this report for their willingness to support improvements in
ongoing support and involvement. this area of care.
We would also like to thank the
About this report
This report is intended for healthcare in relation to the management of
organisations, policymakers and the chronic asthma in children aged 16
public to help improve patient safety years and under.
3
Our investigations
Our investigators and analysts have Maternity investigations
diverse experience of healthcare and
other safety-critical industries and We investigate all incidents in NHS
are trained in human factors and maternity services that meet:
safety science. We consult widely
in England and internationally to • the criteria of the Royal College of
ensure that our work is informed Obstetricians and Gynaecologists’
by appropriate clinical and other Each Baby Counts programme, or
relevant expertise.
• our HSIB defined criteria for
We undertake patient safety maternal deaths.
investigations through two
programmes: Incidents are referred to us by the
NHS trust where the incident took
National investigations place, and, where an incident meets
the criteria, our investigation replaces
Concerns about patient safety in the trust’s own local investigation. Our
any area of NHS-funded healthcare investigation report is shared with
in England can be referred to us by the family and trust, and the trust is
any person, group or organisation. responsible for carrying out any safety
We review these concerns recommendations made in the report.
against our investigation criteria In addition, we identify and examine
to decide whether to conduct a recurring themes that arise from trust-
national investigation. National level investigations in order to make
investigation reports are published safety recommendations to local and
on our website and include safety national organisations for system-level
recommendations for specific improvements in maternity services.
organisations. These organisations
are requested to respond to our For full information on our national
safety recommendations within 90 and maternity investigations please
days, and we publish their responses visit our website.
on our website.
4
Executive Summary
The purpose of this investigation is to In early July 2019, the Child was
help improve patient safety in relation admitted to hospital following
to the management of chronic (long- a near-fatal asthma attack. He
term) asthma in children aged 16 remained in the paediatric intensive
years and under. It uses a real patient care unit for a period of 13 days. He
safety incident involving a child with was eventually discharged home
asthma, referred to as ‘the reference almost seven weeks after admission
event’, to examine this issue. to hospital, with an ongoing plan for
community therapy support.
The reference event
The national investigation
The reference event relates to a Child
who suffered a near-fatal asthma Safety risk
attack when he was five years old.
The Department of Health and Social
The Child was born prematurely and Care shared with HSIB a report to
during his early years had a number Prevent Future Deaths (PFD) from
of health issues, including a form of HM Coroner relating to a child aged
chronic lung disease. Secondary to 10 years, who had died of asthma.
this, he had a ‘wheeze’ (whistling HSIB was asked to consider whether
sound made during breathing) it could identify further opportunities
and suffered from a ‘wet cough’ for learning. Prior to this, there had
(producing mucus). been two other PFD reports relating
to the deaths of children between
Due to his complex and varying health 2014 and 2017, and all three cases
needs, the Child attended hospital highlighted missed opportunities to
frequently either as an outpatient, an recognise asthma as a chronic and
inpatient or for emergency care. The life-threatening condition. There were
Child was prescribed medication to issues around how the condition was
treat his respiratory (airway-related) managed across both primary and
conditions, including corticosteroid secondary care (for example, across
taken using an inhaler. This is a GP practices and hospital-based
medicine that reduces inflammation clinics), and concerns that care did
in the airways. However, medicines not meet national standards.
adherence was an issue – that is, he
was not being given the corticosteroid HSIB identified a reference event
medication in line with the prescriber’s through a review of the Strategic
instructions. In addition, a lack of Executive Information System (StEIS),
capacity in the respiratory outpatient a national database of serious
clinic meant he often waited much patient safety incidents. Additional
longer for an appointment to review information was then gathered and
his condition than was requested by the incident assessed against HSIB’s
the clinic consultant. investigation criteria. Consequently,
5the Chief Investigator authorised a North Care Record as an effective
national investigation. means of sharing clinical information
The national investigation focused on: • interviews with parents of children
with confirmed or suspected asthma
• the implications for children aged 16 to gain a wider perspective of the
years and under of having no formal condition, including management,
diagnosis of asthma support, and treatment
• the current systems of oversight of • focus groups with children and young
care and review of their effectiveness people to better understand asthma
from the patient’s perspective
• the current mechanisms of sharing
clinical information • engagement with a consultant
paediatrician subject matter advisor
• the factors which influence parental (SMA)
adherence to treatment plans for
children aged 16 years and under. • engagement with a human factors SMA
The following work was carried out • engagement with a Professor of
during the investigation: Behavioural Medicine from University
College London, to better understand
• extensive reviews of research and the factors which influence parental/
other literature relevant to each of child adherence to treatment.
the lines of inquiry
The investigation identified
• engagement with experts in the opportunities and system-wide
field of asthma, nationally and solutions to reduce the risk of
internationally acute asthma attacks in children
and adolescents that result in
• exploration of the systems currently significant harm. The investigation
employed in primary care for and the report focus primarily
managing the barriers to asthma care on chronic asthma in children
aged 16 years and under in the
• engagement with the BeatAsthma+ context of safe management of the
team and a consultant respiratory condition between different types
paediatrician (a specialist in the of healthcare services. However, the
treatment of children with airway- findings, safety recommendations
related conditions) to discuss and safety observations may be
diagnostic hubs helpful when considering adults with
asthma and the management of
• engagement with a representative other long-term conditions.
from the Royal College of General
Practitioners to review the Great
6Findings the Child’s suspected asthma
diagnosis between primary care,
The investigation found that: secondary care, community services,
the child’s school and the family.
• For children under-five with wheeze
(a whistling sound made during • There are no nationally endorsed
breathing) without a confirmed training packages for healthcare
diagnosis of asthma, the use of an professionals caring for children
information and management plan with asthma.
to monitor symptoms and adjust
treatment serves to educate parents/ • A combination of paper records
carers regarding symptoms, and and electronic systems, and the
empower them to self-manage their limited ability of different electronic
child’s condition. systems to share information
with one another, resulted in
• In the reference event, monitoring inconsistent and incomplete transfer
of the Child’s response to medicines of information about the Child’s
was limited due to issues with the condition and treatment.
timeliness of follow-up paediatric
respiratory outpatient appointments. • The interface between primary care
and community pharmacy was limited
• The National Review of Asthma in relation to asthma medicines
Deaths identified that a different, management due to the pharmacy
more effective and integrated having only partial access to the Child’s
approach to asthma care delivery Summary Care Record (an electronic
was needed. The review made 19 record of patient information, created
recommendations, 12 of which were from GP medical records, which can be
relevant to the reference event. seen and used by staff in other parts of
Only one has been implemented the health and care system).
nationally to date.
• There was no correlation of ‘red flag’
• The information used by NHS 111 markers such as the number of times
to triage a breathless child over a patient had sought emergency
five years of age does not include treatment, lack of improvement of
a prompt for chest recession (an symptoms and insufficient inhaled
indrawn chest, which can indicate corticosteroid prescriptions. This
breathing difficulties) in the meant it was not possible for primary
supporting information, as one of care and community services to
the indicators of a life-threatening identify patients at increased risk of
breathing difficulty. an asthma attack.
• There was limited communication • Monitoring parental adherence
and transfer of information regarding to asthma medicines was limited
7in terms of effectively changing based interventions, such as
health-related behaviour, since the standardised information and wheeze
reason for nonadherence was not management plans, for the parents/
established. carers of pre-school children. This will
be undertaken in conjunction with the
• There was minimal parental British Paediatric Respiratory Society.
education to enhance the Mother’s
understanding of how to manage her Safety recommendation R/2021/125:
son’s condition, prior to the near-fatal HSIB recommends that NHS England
asthma attack. and NHS Improvement reviews
the recommendations arising from
• The involvement of a paediatric the National Review of Asthma
asthma nurse after the Child’s asthma Deaths to prioritise and ensure the
attack enabled information and key implementation of recommendations
messages to be communicated to that are outstanding.
the Child’s Mother in a way that she
understood. Safety recommendation R/2021/126:
HSIB recommends that NHS Digital
• There appears to be a general lack reviews the supporting information
of understanding about the potential for triaging the breathless child up to
seriousness of asthma. 16 years of age, to determine whether
there are features of life-threatening
• There are no nationally endorsed breathing difficulty.
educational resources for children
and families on the management of Safety recommendation R/2021/127:
asthma (confirmed or suspected). HSIB recommends that NHS
England and NHS Improvement
• Children too young to consent were supports clinical experts to work
not eligible for advanced pharmacy with professional bodies to develop
services (Medicines Use Reviews training competencies for healthcare
and the New Medicines Service) professionals with responsibility for
that could assist their families caring for children with suspected or
in medicines management and confirmed asthma.
adherence to treatment.
Safety recommendation R/2021/128:
HSIB makes the following HSIB recommends that NHS
safety recommendations England and NHS Improvement and
NHSX identify and integrate data
Safety recommendation R/2021/124: items into information technology
HSIB recommends that NHS systems to develop a greater
England and NHS Improvement, as a understanding of the risk factors
commissioning body, supports local present in the community.
systems to implement evidence-
8Safety recommendation R/2021/129: Safety observation O/2021/108:
HSIB recommends that NHSX, It may be beneficial for a health
supported by NHS England and intervention to be delivered to enhance
NHS Improvement, implements the general public’s knowledge and
a discovery programme into the understanding of asthma, emphasising
roadmap for the digital personal the potential seriousness of the
child health record focused on condition. This could be linked to the
developing support, self-reporting modernisation of the Healthy Child
and alerting for asthma self-care. Programme, which is being led by
Public Health England.
Safety recommendation R/2021/130:
HSIB recommends that Public Health Safety observation O/2021/109:
England develops resources for young It may be beneficial if every
people and their parents/carers to child with asthma (confirmed or
raise awareness and enable them to suspected) has access to a healthcare
self-manage asthma more effectively. professional who has been trained
in accordance with a nationally
HSIB makes the following recognised training programme
safety observations and undertakes regular reviews and
continuing educational support.
Safety observation O/2021/105:
It may be beneficial if suspected HSIB notes the following
or possible asthma diagnosis is safety actions
communicated by secondary care
services to children, families, and other Safety action A/2021/038:
care sectors, when asthma is being There is now an alternative vaccine
considered as a possibility (but not for those children whose parents
formally diagnosed). refuse the nasal flu vaccine due to the
porcine gelatine content. Children in a
Safety observation O/2021/106: higher risk group are eligible to receive
It may be beneficial if children were an injectable vaccine as an alternative
coded as having suspected asthma to the nasal vaccine.
if under five years of age and on
inhalers without an asthma diagnosis, Safety action A/2021/039:
recognising that the lack of a formal NHS England and NHS Improvement
diagnosis leads to suboptimal care. is amending the guidance for the
directed enhanced service on
Safety observation O/2021/107: Structured Medication Reviews and
It may be beneficial if diagnostic medicines optimisation to clarify and
hubs are introduced into all regions raise awareness that children, even
in England, modelling those already those too young to give consent, are
in existence, to provide specialist eligible to receive these services.
equipment and expertise to patients
with asthma.
9Safety action A/2021/040:
NHS England and NHS Improvement
is amending the service specification
for the New Medicines Service, so
that it is available to patients of all
ages, including younger children with
parental/guardian consent, who may
benefit from the service.
10WWW.HSIB.ORG.UK
@hsib_org
Further
information
More information about HSIB – including
its team, investigations and history – is
available at www.hsib.org.uk
If you would like to request an
investigation then please read our
guidance before contacting us.
@hsib_org is our Twitter handle.
We use this feed to raise awareness of
our work and to direct followers to our
publications, news and events.
Contact us
If you would like a response to a query or
concern please contact us via email using
enquiries@hsib.org.uk
We monitor this inbox during normal office
hours - Monday to Friday (not bank holidays)
from 09:00 hours to 17:00 hours. We aim to
respond to enquiries within five working days.
To access this document in a different format
– including braille, large-print or easy-read –
please contact enquiries@hsib.org.uk
© Healthcare Safety Investigation Branch copyright 2021. Any enquiries
regarding this publication should be sent to us at enquiries@hsib.org.uk
Click here for contents page 12You can also read
