Daniel KLOSI · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 14 Aug 2024•Inner North London

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

View original report
Concerns
2

Raised in this report

Recipients
3

Named on the report

Responses found
3

Of 3 recipients

Stated actions
25

Described in responses

Recipients and published responses

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised2

  1. Failure to explicitly emphasise prompt escalation when observations cannot be obtained
    Part of recurring concern: Unreliable escalation of abnormal clinical observations
  2. Emergency department electronic patient records failing to show repeat presentations during the current illness
    Part of recurring concern: Incomplete, inaccurate or unavailable clinical and care records

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.25

  1. Royal Free London NHS Foundation Trust

    Use a mandated sepsis assessment tool in the initial paediatric triage electronic patient record.

  2. Royal Free London NHS Foundation Trust

    Integrate the new national PEWS, updated paediatric sepsis bundle and alerts system into the electronic patient record.

  3. Royal Free London NHS Foundation Trust

    Deliver training on deteriorating children, paediatric early warning and sepsis tools, and SBAR escalation.

  4. Royal Free London NHS Foundation Trust

    Provide staff training on the new national PEWS, updated paediatric sepsis bundle and alerts system.

  5. Royal Free London NHS Foundation Trust

    Deliver simulation teaching on managing neurodiverse children and provide distraction kits for clinical assessments.

  6. Royal Free London NHS Foundation Trust

    Monitor adherence to the ongoing patient-safety improvement plans.

  7. Royal Free London NHS Foundation Trust

    Display an electronic patient record icon identifying attendances within the previous 30 days.

  8. Royal Free London NHS Foundation Trust

    Maintain a senior nurse champion to lead training on deteriorating children and audit knowledge and clinical case management.

  9. Royal Free London NHS Foundation Trust

    Ratify and disseminate guidance requiring unobtainable observations to be considered and escalated like abnormal observations.

  10. Royal Free London NHS Foundation Trust

    Implement a group-wide pathway ensuring children who reattend emergency departments are seen by the next available doctor.

  11. Royal Free London NHS Foundation Trust

    Run refresher and induction training on identifying electronic patient record icons for recent attendances.

  12. Royal College of Emergency Medicine

    Support early escalation of care when vital signs cannot be obtained.

  13. Royal College of Emergency Medicine

    Maintain guidance requiring senior review for patients re-attending emergency departments within 72 hours.

  14. Royal College of Emergency Medicine

    Endorse emergency care standards for children.

  15. Royal College of Emergency Medicine

    Publish guidance highlighting the patient-safety consequences of emergency department crowding.

  16. Royal College of Emergency Medicine

    Publish and maintain a learning disabilities toolkit and accompanying educational article for emergency care.

  17. Royal College of Emergency Medicine

    Continue developing a paediatric early warning score for children attending emergency departments.

  18. Royal College of Emergency Medicine

    Provide educational material on Group A Streptococcus and related illnesses.

  19. Royal College of Paediatrics and Child Health

    Share anonymised report information and the anticipated NICE response with the Clinical Quality in Practice Committee for discussion.

  20. Royal College of Paediatrics and Child Health

    Collaborate with NHS England and the Royal College of Nursing to develop a single national Paediatric Early Warning System for England.

  21. Royal College of Paediatrics and Child Health

    Introduce, embed and standardise Paediatric Early Warning Systems across the four nations.

  22. Royal College of Paediatrics and Child Health

    Continue advocating for improved data linkage and information sharing in development of the NHS 10 Year Plan for England.

  23. Royal College of Paediatrics and Child Health

    Audit, review, revise and update emergency care standards, including guidance for neurodivergent children and young people, for publication in 2025.

  24. Royal College of Paediatrics and Child Health

    Share information and local improvement suggestions from the report with paediatric members through the patient safety portal.

  25. Royal College of Paediatrics and Child Health

    Share the report with senior paediatric colleagues.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Royal College of Emergency Medicine

    NHS England should address emergency department electronic record configuration showing previous presentations with the same signs and symptoms.

    Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
  2. Royal College of Paediatrics and Child Health

    Unobtainable observations should not automatically be treated like worrying observations because there are multiple reasons and assessment is holistic.

    Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
  3. Royal College of Paediatrics and Child Health

    Responsibility for electronic patient records lies with the NHS, rather than the College.

    Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to explicitly emphasise prompt escalation when observations cannot be obtained

Wider context from the report

“1. It was difficult for the nursing staff to obtain Daniel’s observations because he was so distressed. That was understandable, but because of the long wait in a busy department, it meant that on the fourth attendance Daniel did not have a full set of observations for over four hours and shortly afterwards suffered a catastrophic cardiovascular compromise. I heard that obtaining no observations should be regarded in the same light as obtaining worrying observations, and should be escalated without delay. It seems that this has not been emphasised explicitly to nursing and medical staff at the trust – and obviously may not have been in other trusts. ”

Is this part of a recurring concern?

Yes — Unreliable escalation of abnormal clinical observations.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Emergency department electronic patient records failing to show repeat presentations during the current illness

Wider context from the report

“2. The trust emergency department electronic patient records do not show how many times a patient has presented to hospital with the same signs and symptoms during their current illness – and of course this may be the case in other emergency departments. ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records.

Open source report

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Use a mandated sepsis assessment tool in the initial paediatric triage electronic patient record.

Verbatim wording from the response

“There is a mandated sepsis assessment tool within the initial paediatric triage form on the EPR (Electronic Patient Record) that has been implemented to support the assessment and recognition of a child with sepsis. This tool works in conjunction with the Manchester Triage System tool and local sepsis guidelines.”

Source location

Response from Royal Free London Hospital
Page 1 · response
Published 21 August 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Integrate the new national PEWS, updated paediatric sepsis bundle and alerts system into the electronic patient record.

Verbatim wording from the response

“In addition, the Trust will be implementing the new national PEWS (Paediatric Early Warning Score) that has been mandated by NHSE as well as the updated paediatric sepsis bundle of care and alerts system. This is being integrated into the EPR and there will be a programme of staff training.”

Source location

Response from Royal Free London Hospital
Page 2 · response
Published 21 August 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Deliver training on deteriorating children, paediatric early warning and sepsis tools, and SBAR escalation.

Verbatim wording from the response

““More training has been given and reflection has been undertaken”.”

Source location

Response from Royal Free London Hospital
Page 1 · response
Published 21 August 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Provide staff training on the new national PEWS, updated paediatric sepsis bundle and alerts system.

Verbatim wording from the response

“In addition, the Trust will be implementing the new national PEWS (Paediatric Early Warning Score) that has been mandated by NHSE as well as the updated paediatric sepsis bundle of care and alerts system. This is being integrated into the EPR and there will be a programme of staff training.”

Source location

Response from Royal Free London Hospital
Page 2 · response
Published 21 August 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Deliver simulation teaching on managing neurodiverse children and provide distraction kits for clinical assessments.

Verbatim wording from the response

““The trust is trying to gain a more sophisticated understanding of the ways in which neurodiverse patients can present and how best to interpret their presentation”.”

Source location

Response from Royal Free London Hospital
Page 2 · response
Published 21 August 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Monitor adherence to the ongoing patient-safety improvement plans.

Verbatim wording from the response

“The Trust is committed to ensuring that the lessons are learned from Daniel’s tragic death and to continue to identify opportunities to improve patient safety. The Trust will be monitoring the adherence to these ongoing improvement plans.”

Source location

Response from Royal Free London Hospital
Page 3 · response
Published 21 August 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Display an electronic patient record icon identifying attendances within the previous 30 days.

Verbatim wording from the response

“2. “The trust emergency department electronic patient records do not show how many times a patient has presented to hospital with the same signs and symptoms during their current illness – and of course this may be the case in other emergency departments”.”

Source location

Response from Royal Free London Hospital
Page 2 · response
Published 21 August 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Maintain a senior nurse champion to lead training on deteriorating children and audit knowledge and clinical case management.

Verbatim wording from the response

“The Royal Free Hospital Paediatric Emergency Department team can confirm that training has occurred in relation to children with a deteriorating condition. This links to the use of the Paediatric Early Warning Score tool as well as the identifying sepsis tool. Staff have also been re-familiarised with escalating this information using the SBAR (Situation, Background, Assessment, Recommendation) communication tool. A child who has a deteriorating condition Nurse Champion has been appointed as a senior nurse with a specialist interest in this situation. This person is responsible for leading on training with members of the paediatric nursing team and for undertaking audits to monitor knowledge and the management of such clinical cases.”

Source location

Response from Royal Free London Hospital
Page 1 · response
Published 21 August 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Ratify and disseminate guidance requiring unobtainable observations to be considered and escalated like abnormal observations.

Verbatim wording from the response

“1. “It was difficult for the nursing staff to obtain Daniel’s observations because he was so distressed. That was understandable, but because of the long wait in a busy department, it meant that on the fourth attendance Daniel did not have a full set of observations for over four hours and shortly afterwards suffered a catastrophic cardiovascular compromise. I heard that obtaining no observations should be regarded in the same light as obtaining worrying observations and should be escalated without delay. It seems that this has not been emphasised explicitly to nursing and medical staff at the trust”.”

Source location

Response from Royal Free London Hospital
Page 2 · response
Published 21 August 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Implement a group-wide pathway ensuring children who reattend emergency departments are seen by the next available doctor.

Verbatim wording from the response

““A child reattending the emergency department will now be seen by the next available doctor, rather than waiting for a paediatrician to become available”.”

Source location

Response from Royal Free London Hospital
Page 1 · response
Published 21 August 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Run refresher and induction training on identifying electronic patient record icons for recent attendances.

Verbatim wording from the response

“The Trust can confirm that for patients who reattend an icon is visible next to the patients name on EPR indicating previous attendances within 30 days. The Trust is running refresher training on identifying these icons, and this is covered at the digital training induction for all new medical staff.”

Source location

Response from Royal Free London Hospital
Page 2 · response
Published 21 August 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Support early escalation of care when vital signs cannot be obtained.

Verbatim wording from the response

“The RCEM is an active participant in the national initiative to develop an early warning score (that utilises observations or vital signs) that is specifically designed for use on all children attending emergency departments, following the implementation of a paediatric early warning score for children who are in hospital wards [11]. We will continue to develop supportive of this initiative and support the need for early escalation of care for those patients in whom it is not possible to undertake vital signs.”

Source location

Response from RCEM
Page 2 · response
Published 21 August 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Maintain guidance requiring senior review for patients re-attending emergency departments within 72 hours.

Verbatim wording from the response

“The Royal College of Emergency Medicine (RCEM) has specific guidance for patients who re-attend emergency departments within 72 hours [1] to ensure that they are reviewed by a senior doctor. RCEM have also endorsed the Royal College of Paediatrics and Child Health Standards in Emergency Care document [2]. RCEM have also produced specific educational material relating Group A Streptococcus [3,4]. RCEM have recently published a Learning Disabilities toolkit [5] as well as an accompanying article on Learning Disabilities in the supplement of the Emergency Medicine Journal [6]. I am sure you are also aware that the Oliver McGowan training programme on Learning Disability and Autism is now a mandatory requirement for healthcare workers [7].”

Source location

Response from RCEM
Page 1 · response
Published 21 August 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Endorse emergency care standards for children.

Verbatim wording from the response

“The Royal College of Emergency Medicine (RCEM) has specific guidance for patients who re-attend emergency departments within 72 hours [1] to ensure that they are reviewed by a senior doctor. RCEM have also endorsed the Royal College of Paediatrics and Child Health Standards in Emergency Care document [2]. RCEM have also produced specific educational material relating Group A Streptococcus [3,4]. RCEM have recently published a Learning Disabilities toolkit [5] as well as an accompanying article on Learning Disabilities in the supplement of the Emergency Medicine Journal [6]. I am sure you are also aware that the Oliver McGowan training programme on Learning Disability and Autism is now a mandatory requirement for healthcare workers [7].”

Source location

Response from RCEM
Page 1 · response
Published 21 August 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Publish guidance highlighting the patient-safety consequences of emergency department crowding.

Verbatim wording from the response

“We note that Daniel was taken to an emergency department that was clearly struggling to cope with the demands which were being placed upon it, resulting in long waits. As a medical royal college, we have been raising concerns nationally for a considerable period of time regarding the adverse consequences of prolonged length of stay in EDs / ED Crowding. Our own publication highlights the consequences of ED crowding and its negative impact on adverse events, prolonged hospital stays, and increased mortality and morbidity [8]. Delays in assessment and diagnosis are features of crowded emergency departments; the Health Services Safety Investigation Body (HSSIB) have published a series of reports which also highlights the impact of these same factors in patient safety incidents [9]. We are also aware”

Source location

Response from RCEM
Page 1 · response
Published 21 August 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Publish and maintain a learning disabilities toolkit and accompanying educational article for emergency care.

Verbatim wording from the response

“The Royal College of Emergency Medicine (RCEM) has specific guidance for patients who re-attend emergency departments within 72 hours [1] to ensure that they are reviewed by a senior doctor. RCEM have also endorsed the Royal College of Paediatrics and Child Health Standards in Emergency Care document [2]. RCEM have also produced specific educational material relating Group A Streptococcus [3,4]. RCEM have recently published a Learning Disabilities toolkit [5] as well as an accompanying article on Learning Disabilities in the supplement of the Emergency Medicine Journal [6]. I am sure you are also aware that the Oliver McGowan training programme on Learning Disability and Autism is now a mandatory requirement for healthcare workers [7].”

Source location

Response from RCEM
Page 1 · response
Published 21 August 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Continue developing a paediatric early warning score for children attending emergency departments.

Verbatim wording from the response

“The RCEM is an active participant in the national initiative to develop an early warning score (that utilises observations or vital signs) that is specifically designed for use on all children attending emergency departments, following the implementation of a paediatric early warning score for children who are in hospital wards [11]. We will continue to develop supportive of this initiative and support the need for early escalation of care for those patients in whom it is not possible to undertake vital signs.”

Source location

Response from RCEM
Page 2 · response
Published 21 August 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Provide educational material on Group A Streptococcus and related illnesses.

Verbatim wording from the response

“The Royal College of Emergency Medicine (RCEM) has specific guidance for patients who re-attend emergency departments within 72 hours [1] to ensure that they are reviewed by a senior doctor. RCEM have also endorsed the Royal College of Paediatrics and Child Health Standards in Emergency Care document [2]. RCEM have also produced specific educational material relating Group A Streptococcus [3,4]. RCEM have recently published a Learning Disabilities toolkit [5] as well as an accompanying article on Learning Disabilities in the supplement of the Emergency Medicine Journal [6]. I am sure you are also aware that the Oliver McGowan training programme on Learning Disability and Autism is now a mandatory requirement for healthcare workers [7].”

Source location

Response from RCEM
Page 1 · response
Published 21 August 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Share anonymised report information and the anticipated NICE response with the Clinical Quality in Practice Committee for discussion.

Verbatim wording from the response

“The College will be sharing information and suggestions for local improvement from your report with our paediatric members via its patient safety portal. The anonymised information within your report, and anticipated response from NICE, will also be shared for discussion with the RCPCH Clinical Quality in Practice Committee, where further actions may be identified.”

Source location

Response from RCPCH
Page 2 · response
Published 21 August 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Collaborate with NHS England and the Royal College of Nursing to develop a single national Paediatric Early Warning System for England.

Verbatim wording from the response

“As a college we are committed to the introduction, embedding and appropriate standardisation of Paediatric Early Warning Systems (PEWS) within the four nations. PEWS are designed to effectively recognise and respond to the deterioration of children or young people in a healthcare environment. A parental escalation process is essential to any effectively PEWS. We have been collaborating with NHS England and the Royal College of Nursing to develop a single national PEWS for England since 2018 and are supportive of equivalent processes across the UK.”

Source location

Response from RCPCH
Page 1 · response
Published 21 August 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Introduce, embed and standardise Paediatric Early Warning Systems across the four nations.

Verbatim wording from the response

“As a college we are committed to the introduction, embedding and appropriate standardisation of Paediatric Early Warning Systems (PEWS) within the four nations. PEWS are designed to effectively recognise and respond to the deterioration of children or young people in a healthcare environment. A parental escalation process is essential to any effectively PEWS. We have been collaborating with NHS England and the Royal College of Nursing to develop a single national PEWS for England since 2018 and are supportive of equivalent processes across the UK.”

Source location

Response from RCPCH
Page 1 · response
Published 21 August 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Continue advocating for improved data linkage and information sharing in development of the NHS 10 Year Plan for England.

Verbatim wording from the response

“Responsibility for electronic records lies with the NHS. As a college we have called for improved data and digital solutions in our Blueprint for Transforming Child Health Services. Effective data linkage and information sharing within the health system, and between the health system and key partners in education and children’s social care is vital to understanding children’s health needs, recognising risk of harm, and providing effective care. We will continue to advocate on this as a priority in the development of the new 10 Year Plan for the NHS in England.”

Source location

Response from RCPCH
Page 2 · response
Published 21 August 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Audit, review, revise and update emergency care standards, including guidance for neurodivergent children and young people, for publication in 2025.

Verbatim wording from the response

“Our Facing the Future standards aim to provide a vision of how paediatric care can be delivered to provide a safe and sustainable, high-quality service that meets the health needs of every child and young person. There are standards covering emergency settings. These standards aim to ensure that urgent and emergency care is fully integrated to ensure children are seen by the right people, at the right place and in the right setting. We are currently in the process of audit, review and revision and update of our current standards, to be published in 2025.”

Source location

Response from RCPCH
Page 1 · response
Published 21 August 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Share information and local improvement suggestions from the report with paediatric members through the patient safety portal.

Verbatim wording from the response

“The College will be sharing information and suggestions for local improvement from your report with our paediatric members via its patient safety portal. The anonymised information within your report, and anticipated response from NICE, will also be shared for discussion with the RCPCH Clinical Quality in Practice Committee, where further actions may be identified.”

Source location

Response from RCPCH
Page 2 · response
Published 21 August 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Share the report with senior paediatric colleagues.

Verbatim wording from the response

“Thank you for sharing your report with us regarding the tragic and untimely passing of Daniel Klosi. I was very sorry to hear of Daniel’s death. I have shared your report with other senior paediatric colleagues within RCPCH.”

Source location

Response from RCPCH
Page 1 · response
Published 21 August 2024

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

NHS England should address emergency department electronic record configuration showing previous presentations with the same signs and symptoms.

Verbatim wording from the response

“With regards your specific concerns about emergency department electronic patient records (EPR) and their configuration to show how many times a patient has presented to hospital with the same signs and symptoms as their current presentation, we feel this question is best directed towards NHS England.”

Source location

Response from RCEM
Page 2 · response
Published 21 August 2024

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Unobtainable observations should not automatically be treated like worrying observations because there are multiple reasons and assessment is holistic.

Verbatim wording from the response

“1. I heard that obtaining no observations should be regarded in the same light as obtaining worrying observations and should be escalated without delay.”

Source location

Response from RCPCH
Page 1 · response
Published 21 August 2024

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Responsibility for electronic patient records lies with the NHS, rather than the College.

Verbatim wording from the response

“2. The trust emergency department electronic patient records do not show how many times a patient has presented to hospital with the same signs and symptoms during their current illness”

Source location

Response from RCPCH
Page 2 · response
Published 21 August 2024

Open published response
Back to top

Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026