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External reports

Sheffield Children's Hospital

5 October 2023

An independent investigation into the care and treatment of Yusuf: York Road Surgery, Yorkshire Ambulance Service NHS Trust, The Rotherham NHS Foundation Trust, Sheffield Children’s NHS Foundation Trust

We have published this report into the care and treatment of Yusuf alongside our response to the recommendations (published October 2023). 

The report

Sheffield Children’s response to the report

This report deals with difficult subjects relating to care and treatment of a child. We advise caution in those who may be triggered by reading information which might be sometimes distressing, particularly, that they are helped to read this report in a safe and supported way.

Sheffield Children’s Assurance Statement

This assurance statement has been published alongside the independent report of the investigation into the death of Yusuf Nazir at Sheffield Children’s NHS Foundation Trust on 23 November 2022. This statement sets out our response to the investigation report and says what we plan to do in relation to each of the three recommendations for our Trust.

We welcome this report from Niche Consulting, on behalf of the South Yorkshire Integrated Care Board. The Board of Directors at Sheffield Children’s NHS Foundation Trust wholly commit to deliver on the improvements outlined in the recommendations of this review.

We express our deepest condolences to Yusuf’s family for their loss. The death of a child is tragic and the loss of any child while they are a patient here at Sheffield Children’s is something we take very seriously. Colleagues that cared for Yusuf have been impacted by his loss and share these condolences.

Our colleagues pride themselves on providing the best care for all children and young people who need it. We have taken the learning and recommendations from this report and are putting into practice the necessary changes across the Trust to improve our care for our children and young people.

Colleagues provided Yusuf with the best care possible before he died. The report does, however, make some recommendations for learning and improved practice within the Trust, and other organisations, going forward.

Please note that the following information about Yusuf’s death may be upsetting to read. Our colleagues who looked after Yusuf are being supported directly, and we have worked closely with them around the investigation.


Overview of Sheffield Children’s NHS Foundation Trust

Sheffield Children’s provide care for children and young people across community, acute specialist settings and mental health services from community to highly specialist in-patient care.

The Trust offers a comprehensive approach to supporting children and families, with the aim to be at the forefront of best practice in delivering high quality and integrated care to children and young people. Services are provided in a number of different locations.

The majority of acute care is provided at the Sheffield Children’s Hospital which is situated on Western Bank, a central location in the city. It is in close proximity to Sheffield’s universities and many of the facilities offered by Sheffield Teaching Hospitals.

Sheffield Children’s community and mental health services are provided from a number of locations. The Ryegate Children’s Centre is situated a mile away from Sheffield Children’s Hospital, in the south-west of the city and provides a focus for the delivery of services to children with disabilities, including those with complex neuro-disability.

Mental health and community services are provided from sites across the city of Sheffield, including Flockton House, Centenary House and the Becton Centre for Children and Young People.

Our services extend to care delivered directly in the home, with our Helena Nursing Team providing 24-hour respite care, advice, specialist nursing, and palliative care to children with complex neurological disabilities within their own homes. We also host Embrace, an accredited critical care transport service based in Barnsley.

In 2022, we launched our Clinical Strategy for a healthier future based around five themes of:

  • Integrated care
  • Care where needed
  • Centre of excellence
  • Health inequalities and inclusion
  • Healthy lives

Later this year, we will launch our new Quality Promise based around care that is safe, kind and outstanding.

What is the report about and why has it been commissioned? 

Yusuf died at Sheffield Children’s Hospital on 23 November 2022. Before coming to Sheffield Children’s Yusuf had been seen by his GP and Rotherham Hospital Urgent and Emergency Care Centre. Yorkshire Ambulance Service transferred Yusuf from home on the 18 November to Sheffield Children’s where he was cared for across the Emergency Department, Ward 4 and our Paediatric Intensive Care Unit (PICU).

Yusuf’s death certificate states that he died of type 1 respiratory failure, pneumonia and tonsillitis. Despite a wide range of treatments, Yusuf developed multiorgan failure and suffered several cardiac arrests which he did not survive.

Following Yusuf’s death, and a meeting with the family on 2 December, The Rotherham NHS Foundation Trust decided that the complaint should be a serious incident requiring investigation and South Yorkshire Integrated Care Board commissioned an external independent investigation into the care and treatment that Yusuf had received.

The investigation was led by a partner and director from Niche Consulting and the panel included clinical expertise from a consultant paediatrician with experience in emergency paediatric care, a GP who is a senior partner and primary care board member on an integrated care board, and a consultant paramedic in emergency care.

The investigation report contains the following recommendations for Sheffield Children’s:

Recommendation 1: Clinical care – cannulation management

What was recommended:

  • We did not see evidence of cannula patency having been documented and cannot be assured of the quality of cannulation management. The Trust must ensure that all staff giving antibiotics intravenously check the line is unobstructed before each dose and document regular checks on peripheral IV lines when in situ (visual infusion phlebitis (VIP) score).
  • We noted time delays between the prescribing of drugs and their administration. The Trust must ensure that prescribed drugs (in particular antibiotics) are given as soon as possible after prescribing decisions are made. This should be audited in the emergency department (ED), the wards and the PICU.

Trust action

We are sorry that some of our cannulation management procedures during Yusuf’s care fell short of what was needed. We will ensure our current cannula care guidelines will be updated to include current practice including ANTT (Aseptic Non-Touch Technique) scoring and the use of the VIP score on fluid balance charts will be reviewed.

To remedy the delays between prescribing of drugs and their administration, we will work with clinical educators to ensure that all nursing colleagues are recording VIP scores hourly and can recognise and respond to complications of peripheral cannulas. We will also consult our IV Practice group to ensure a high standard of IV therapy throughout wards and departments. This group will review and update clinical practice guidelines for IV therapies and central venous access device care and undertake clinical audits to ensure optimal care. Clinical audits will also be undertaken on ANTT and completion of VIP scores.

Recommendation 2:</strong> Post-mortems in children who die unexpectedly

What was recommended:

Yusuf did not have a post-mortem, which has meant there was a missed opportunity to understand his underlying pathology more definitively.

  • The Trust should review its criteria and decision-making in relation to undertaking hospital post-mortems for children who die unexpectedly. This should result in readily available Trust guidelines, considering the values of a multicultural population.
  • Support given to clinicians facing conversations with families in difficult situations should be reviewed to ensure it is adequate, in particular the view of PICU staff should be considered.

Trust action

At Sheffield Children’s we have always followed national guidelines around post-mortems. However, Yusuf’s case has prompted us to reassess our approach and, where appropriate, go beyond those national guidelines, engage fully with families who have sadly lost a child, and make sure their wishes and any cultural sensitivities are considered when deciding whether a post-mortem should be carried out.

We will work with our radiology and pathology teams to develop a standard operating procedure to support culturally sensitive, minimally invasive, post-mortems. This might include investigating only the areas that might be relevant to understanding how the child died. We will also review the Trust’s bereavement pack to include within it criteria to request a hospital post-mortem. This would include a series of prompts for clinicians e.g. Have you considered a post-mortem to find out what happened? Would this help the family?

Recommendation 2: </strong>Nutritional assessments

What was recommended:

A nutritional risk assessment (STAMP) was not completed. The impact of pre-admission reduced nutritional intake was not assessed.

  • The Trust should ensure the STAMP screening is completed accurately on admission as per Trust policy.
  • The Trust should review its STAMP guidance to ensure that pre-admission nutritional status is adequately considered in scoring and care planning. The Trust should make clear what action is expected when a high risk malnutrition score results from STAMP screening with contingencies agreed for out of hours and weekend assessments.

Trust action

We apologise that in this instance a nutritional risk assessment was not performed in line with our procedures.

We have committed to carrying out a scoping exercise to review nutritional assessments used in other paediatric trusts to ensure Sheffield Children’s is adhering to best practice. Furthermore, we will work with ward managers and clinical educators to ensure that nutritional assessments and routine height and weight is completed on admission. Finally, we will undertake clinical audits to ensure nutritional assessments are being completed.

We wish to thank those colleagues who supported the investigation and those who have supported in applying our learning and changes in practice resulting from Yusuf’s care. We take the recommendations seriously and will continue to change our processes and procedures to make our care better for children, young people and their families.

Jeff Perring, Executive Medical Director
Yvonne Millard MBE, Chief Nurse

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