PFD report

Kiarah Faith Adora Allen · Prevention of Future Deaths report

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Issued 21 Aug 2018•Birmingham and Solihull

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
24

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

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

Concerns raised1

  1. Insufficient nursing and clinical staffing for very sick babies
    Part of recurring concern: Insufficient medical staffing capacity for timely patient carePart of recurring concern: Insufficient qualified healthcare staffing capacity
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.5

  1. Action

    Implement the neonatal workforce plan and continue recruitment to restore staffing capacity.

    Stated by Birmingham Women'S and Children'S NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 25 September 2018.
  2. Action

    Allocate nurses to specific babies on every shift and reinforce the allocation process through staff communications.

    Stated by Birmingham Women'S and Children'S NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 September 2018.
  3. Action

    Reconstruct and align the NICU e-roster with the workforce plan.

    Stated by Birmingham Women'S and Children'S NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 September 2018.

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

Insufficient nursing and clinical staffing for very sick babies

Wider context from the report

“1. I heard evidence in the inquest that at the time this incident occurred there were unsafe levels of nursing and clinical staff. The funding provided for nurses assumed the unit was only 85% full. Therefore when the unit was full, there were insufficient numbers of nurses and doctors. Consideration needs to be given to providing additional funding to enable the unit to be appropriately staffed for the very sick babies they care for. ”

Is this part of a recurring concern?

Yes — Insufficient medical staffing capacity for timely patient care; Insufficient qualified healthcare staffing capacity.

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

Implement the neonatal workforce plan and continue recruitment to restore staffing capacity.

Verbatim wording from the response

“• Action 5: A new workforce plan will be developed by the senior leadership in neonates. o The workforce plan is live, but recovery through increased recruitment is on-going.”

Source location

2018-0253-Response-by-Birmimgham-Womanss-and-Childrens-NHS-Trust
Page 2 · response
Published 25 September 2018

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

Allocate nurses to specific babies on every shift and reinforce the allocation process through staff communications.

Verbatim wording from the response

“• Action 2: Nurses are allocated to specific babies each shift. o The nurse in charge (NIC) is allocating babies to nurse every shift. This is being reinforced through the staff weekly newsletter.”

Source location

2018-0253-Response-by-Birmimgham-Womanss-and-Childrens-NHS-Trust
Page 2 · response
Published 25 September 2018

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

Reconstruct and align the NICU e-roster with the workforce plan.

Verbatim wording from the response

“• Action 24: Head of Nursing to complete and implement a NICU workforce plan. o The Workforce plan is being implemented and the NICU e-roster has been reconstructed and aligned to the workforce plan.”

Source location

2018-0253-Response-by-Birmimgham-Womanss-and-Childrens-NHS-Trust
Page 3 · response
Published 25 September 2018

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

Price the Vocera system for staff to summon colleague support.

Verbatim wording from the response

“• Action 13: Head of Nursing to price the vocera system for staff to be able to summon support from colleagues, if required. o Pricing for Vocera for all clinical areas is a current on-going task.”

Source location

2018-0253-Response-by-Birmimgham-Womanss-and-Childrens-NHS-Trust
Page 3 · response
Published 25 September 2018

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

Move babies where possible to support the safest care, while embedding the practice fully.

Verbatim wording from the response

“• Action 9: Previous shift NIC to review babies and move them where necessary. o Within current practice, the NIC is moving babies where ever possible to permit the safest possible care, however this is not yet fully embedded.”

Source location

2018-0253-Response-by-Birmimgham-Womanss-and-Childrens-NHS-Trust
Page 3 · response
Published 25 September 2018

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.19

  1. 1

    Develop and pilot observation charts with a RAG-rated ward-round jobs list.

    Stated by Birmingham Women'S and Children'S NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 25 September 2018.
  2. 2

    Continue working with NHS England to improve neonatal commissioning and funding arrangements.

    Stated by Birmingham Women'S and Children'S NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 25 September 2018.
  3. 3

    Develop a blood-gas-checking simulation training package with a neonatal consultant.

    Stated by Birmingham Women'S and Children'S NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 25 September 2018.
  4. 4

    Embed trolley use, guidance and labeling in PN administration practice.

    Stated by Birmingham Women'S and Children'S NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 September 2018.
  5. 5

    Continue the culture change to keep clinical-room doors open during key tasks when infection control permits.

    Stated by Birmingham Women'S and Children'S NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 25 September 2018.
  6. 6

    Check resuscitation equipment daily and review it regularly through the Leadership and Resuscitation team.

    Stated by Birmingham Women'S and Children'S NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 September 2018.
  7. 7

    Use the approved PN competency covering disposal of old PN.

    Stated by Birmingham Women'S and Children'S NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 September 2018.
  8. 8

    Allocate a named bleep nurse and backup nurse on every shift.

    Stated by Birmingham Women'S and Children'S NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 September 2018.
  9. 9

    Use an approved competency-based checklist for changing PN.

    Stated by Birmingham Women'S and Children'S NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 September 2018.
  10. 10

    Redesign and deliver annual staff training incorporating human factors.

    Stated by Birmingham Women'S and Children'S NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 25 September 2018.
  11. 11

    Use the finalized situation-report form to support handover and baby moves where required.

    Stated by Birmingham Women'S and Children'S NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 September 2018.
  12. 12

    Provide resuscitation leadership and human-factors training to maintain team-leader situational awareness.

    Stated by Birmingham Women'S and Children'S NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 25 September 2018.
  13. 13

    Provide staff presence for witnessed resuscitation and reinforce this through simulation training.

    Stated by Birmingham Women'S and Children'S NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 25 September 2018.
  14. 14

    Create a student liaison role to support training delivery.

    Stated by Birmingham Women'S and Children'S NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 September 2018.
  15. 15

    Use the shift planner incorporated into the handover checklist.

    Stated by Birmingham Women'S and Children'S NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 September 2018.
  16. 16

    Plan site-management service cover for the Women’s site.

    Stated by Birmingham Women'S and Children'S NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 25 September 2018.
  17. 17

    Develop and deliver the neonatal education plan to embed learning.

    Stated by Birmingham Women'S and Children'S NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 25 September 2018.
  18. 18

    Train two nurses to deliver simulation training.

    Stated by Birmingham Women'S and Children'S NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 September 2018.
  19. 19

    Implement the trust-wide PN competency, including staff retraining and assessment before PN administration.

    Stated by Birmingham Women'S and Children'S NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 September 2018.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.2

  1. 1

    ARNI implementation is on hold while the Trust recruits its resuscitation team.

    Stated by Birmingham Women'S and Children'S NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
  2. 2

    ARNI training will complement, not replace, Newborn Life Support because both courses are required.

    Stated by Birmingham Women'S and Children'S NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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

Develop and pilot observation charts with a RAG-rated ward-round jobs list.

Verbatim wording from the response

“• Action 7: Observation charts with a RAG rated ward round jobs list are to be created and implemented. o This project is on-going; the NICU team are working with the medical illustration department to devise a draft chart for piloting.”

Source location

2018-0253-Response-by-Birmimgham-Womanss-and-Childrens-NHS-Trust
Page 3 · response
Published 25 September 2018

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 working with NHS England to improve neonatal commissioning and funding arrangements.

Verbatim wording from the response

“I have had sight of the response from NHS England in regards to the neonatal commissioning arrangements and can confirm that we are continuing to work with our colleagues at NHS England to better understand and improve the commissioning and funding arrangements to support our neonatal service.”

Source location

2018-0253-Response-by-Birmimgham-Womanss-and-Childrens-NHS-Trust
Page 1 · response
Published 25 September 2018

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

Develop a blood-gas-checking simulation training package with a neonatal consultant.

Verbatim wording from the response

“• Action 23: Blood gas checking to be incorporated into the simulation training. o Two nurses have attended training to become able to run simulation training. A plan is being put in place to devise the training package together with a Neonatal Consultant.”

Source location

2018-0253-Response-by-Birmimgham-Womanss-and-Childrens-NHS-Trust
Page 4 · response
Published 25 September 2018

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

Embed trolley use, guidance and labeling in PN administration practice.

Verbatim wording from the response

“• Action 8: The use of the trolley when completing PN to be embedded into the competency for PN. o Trolley use is embedded, with a guide and labels attached.”

Source location

2018-0253-Response-by-Birmimgham-Womanss-and-Childrens-NHS-Trust
Page 2 · response
Published 25 September 2018

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 the culture change to keep clinical-room doors open during key tasks when infection control permits.

Verbatim wording from the response

“• Action 12: The doors of the clinical rooms are to be left open, during key tasks, when infection control allows. o Culture change is on-going.”

Source location

2018-0253-Response-by-Birmimgham-Womanss-and-Childrens-NHS-Trust
Page 3 · response
Published 25 September 2018

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

Check resuscitation equipment daily and review it regularly through the Leadership and Resuscitation team.

Verbatim wording from the response

“• Action 19: Always have a leader during resuscitation who is not task focused and therefore is able to have situational awareness. o The resuscitation equipment is being checked daily and regularly being reviewed by the Leadership and Resuscitation team. Advanced Resuscitation of Newborn Infant (ARNI)”

Source location

2018-0253-Response-by-Birmimgham-Womanss-and-Childrens-NHS-Trust
Page 3 · response
Published 25 September 2018

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

Use the approved PN competency covering disposal of old PN.

Verbatim wording from the response

“• Action 10: Include the disposal of the old PN in the training competency for PN. o The competency document has been approved and is in use.”

Source location

2018-0253-Response-by-Birmimgham-Womanss-and-Childrens-NHS-Trust
Page 2 · response
Published 25 September 2018

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

Allocate a named bleep nurse and backup nurse on every shift.

Verbatim wording from the response

“• Action 3: Each shift a specific nurse should be allocated to hold the bleep and their name is documented on the NIC paperwork. o The bleep is allocated to a specific nurse, and there is also a back up nurse every shift. This is embedded within daily practice.”

Source location

2018-0253-Response-by-Birmimgham-Womanss-and-Childrens-NHS-Trust
Page 2 · response
Published 25 September 2018

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

Use an approved competency-based checklist for changing PN.

Verbatim wording from the response

“• Action 11: A checklist is to be created when PN is being changed, this allows the person to check in and check out of the task. o The competency document has been approved and is in use.”

Source location

2018-0253-Response-by-Birmimgham-Womanss-and-Childrens-NHS-Trust
Page 2 · response
Published 25 September 2018

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

Redesign and deliver annual staff training incorporating human factors.

Verbatim wording from the response

“• Action 22: Human factors training: o The annual staff training day has been redesigned and Human factors will be included in this training which began in September. It will take a year to deliver this to all staff.”

Source location

2018-0253-Response-by-Birmimgham-Womanss-and-Childrens-NHS-Trust
Page 4 · response
Published 25 September 2018

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

Use the finalized situation-report form to support handover and baby moves where required.

Verbatim wording from the response

“• Action 4: The Nurse in charge handover is to be shortened to ensure that the Situation report (SITREP) is completed and babies are moved, if required. o A new sit rep form has been finalised and is in use.”

Source location

2018-0253-Response-by-Birmimgham-Womanss-and-Childrens-NHS-Trust
Page 2 · response
Published 25 September 2018

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 resuscitation leadership and human-factors training to maintain team-leader situational awareness.

Verbatim wording from the response

“• Action 19: Always have a leader during resuscitation who is not task focused and therefore is able to have situational awareness. o The resuscitation equipment is being checked daily and regularly being reviewed by the Leadership and Resuscitation team. Advanced Resuscitation of Newborn Infant (ARNI)”

Source location

2018-0253-Response-by-Birmimgham-Womanss-and-Childrens-NHS-Trust
Page 3 · response
Published 25 September 2018

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 presence for witnessed resuscitation and reinforce this through simulation training.

Verbatim wording from the response

“• Action 20: There should be a member of staff with the parents during witness resuscitation. o Witnessed resuscitation is part of our standard practice and is being reinforced in simulation training.”

Source location

2018-0253-Response-by-Birmimgham-Womanss-and-Childrens-NHS-Trust
Page 3 · response
Published 25 September 2018

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

Create a student liaison role to support training delivery.

Verbatim wording from the response

“• Action 14: An Education Plan will be produced to include the care of the sick neonate and embed learning. A student liaison role has also been created to support delivery of training. o The education plan began in October 2018.”

Source location

2018-0253-Response-by-Birmimgham-Womanss-and-Childrens-NHS-Trust
Page 3 · response
Published 25 September 2018

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

Use the shift planner incorporated into the handover checklist.

Verbatim wording from the response

“• Action 6: A shift planner to be incorporated on the back to the new handover checklist. o The shift planner and handover checklist is launched and in use.”

Source location

2018-0253-Response-by-Birmimgham-Womanss-and-Childrens-NHS-Trust
Page 2 · response
Published 25 September 2018

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

Plan site-management service cover for the Women’s site.

Verbatim wording from the response

“• Action 15: The Women’s site requires site management service cover. o In planning.”

Source location

2018-0253-Response-by-Birmimgham-Womanss-and-Childrens-NHS-Trust
Page 3 · response
Published 25 September 2018

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

Develop and deliver the neonatal education plan to embed learning.

Verbatim wording from the response

“• Action 14: An Education Plan will be produced to include the care of the sick neonate and embed learning. A student liaison role has also been created to support delivery of training. o The education plan began in October 2018.”

Source location

2018-0253-Response-by-Birmimgham-Womanss-and-Childrens-NHS-Trust
Page 3 · response
Published 25 September 2018

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

Train two nurses to deliver simulation training.

Verbatim wording from the response

“• Action 23: Blood gas checking to be incorporated into the simulation training. o Two nurses have attended training to become able to run simulation training. A plan is being put in place to devise the training package together with a Neonatal Consultant.”

Source location

2018-0253-Response-by-Birmimgham-Womanss-and-Childrens-NHS-Trust
Page 4 · response
Published 25 September 2018

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 the trust-wide PN competency, including staff retraining and assessment before PN administration.

Verbatim wording from the response

“• Action 1: A new nursing competency for safe administration of PN has been developed and all staff have been retrained and assessed against the competency before being allowed to continue administering PN. o All eligible staff have been re-educated and assessed against the up to date trust wide PN competency. All new members of staff will attend the study day as part of the new NICU Foundation programme. This has been in place since July 2018.”

Source location

2018-0253-Response-by-Birmimgham-Womanss-and-Childrens-NHS-Trust
Page 2 · response
Published 25 September 2018

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

ARNI implementation is on hold while the Trust recruits its resuscitation team.

Verbatim wording from the response

“• Action 21: Head of Nursing to price the ARNI training for NICU nurses to replace Newborn Life Support (NLS) course. o ARNI was not to replace NLS, but to complement it as both are required. This will form part of the suite of resuscitation courses available across the trust. ARNI implementation is on hold whilst the Resuscitation Team at the Trust is recruited to.”

Source location

2018-0253-Response-by-Birmimgham-Womanss-and-Childrens-NHS-Trust
Page 4 · response
Published 25 September 2018

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

ARNI training will complement, not replace, Newborn Life Support because both courses are required.

Verbatim wording from the response

“• Action 21: Head of Nursing to price the ARNI training for NICU nurses to replace Newborn Life Support (NLS) course. o ARNI was not to replace NLS, but to complement it as both are required. This will form part of the suite of resuscitation courses available across the trust. ARNI implementation is on hold whilst the Resuscitation Team at the Trust is recruited to.”

Source location

2018-0253-Response-by-Birmimgham-Womanss-and-Childrens-NHS-Trust
Page 4 · response
Published 25 September 2018

Open published response
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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