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Improve medical training and safety culture for better paediatric care

BMJ 2006; 333 doi: (Published 02 November 2006) Cite this as: BMJ 2006;333:938
  1. Lisa Hitchen
  1. London

    Substandard management is responsible for 40% of deaths in infants and disability caused by asphyxia at birth, clinicians heard at a paediatric conference this week.

    Umesh Prabhu, a consultant paediatrician and medical director of Bury NHS Trust, told delegates at a meeting on clinical risk management that 140 out of 350 incidents in the United Kingdom in which babies died or were disabled after brain damage could have been avoided.

    “If every trust concentrated on those babies and what can go wrong I think we could do a lot for them, and it would save the NHS £200m [$380m; €300m] a year,” he said.

    Dr Prabhu implemented a clinical risk management approach at his own trust four years ago. As a result, he noted, Bury has not seen any preventable paediatric deaths.

    The trust developed written protocols for common paediatric conditions, which are given out to junior doctors during a three day induction. Regular drills for paediatric emergencies are carried out as well as cardiopulmonary resuscitation training twice a month, Dr Prabhu said.

    “If we can concentrate on 10 important conditions, what are the risks, and how we can manage them, I think we can achieve a lot.”

    Many of Dr Prabhu's suggestions were echoed in the recommendations of a government report on managing acute paediatric cases in district general hospitals.

    Launching the report at the conference, Beverley Hughes, minister for children, families, and young people, said the government acknowledged that the management of ill or injured children was changing: surgery at district general hospitals is in decline and more specialised care is taking place at larger, tertiary centres.

    In particular this was affecting anaesthetists, who have fewer opportunities to become involved in elective paediatric surgery “potentially reducing their ability to manage paediatric emergencies,” the report said.

    The report recommended that anaesthetists in district general hospitals kept up their skills with short attachments to larger centres and that “clear networking arrangements would reduce the chances of an anaesthetist being left in sole charge of a critically sick child.”

    Dirk Meerstadt, a consultant paediatrician at Greenwich Teaching Primary Care Trust, had not read the report but was sceptical: “There is a very real desire by the Department of Health to look at these services [maternity, emergency medicine, and acute paediatrics] and have them concentrated in fewer centres. This will have major implications for their delivery outside of these centres.”

    “It will need to be considered in great depth and the local implications [understood]. My fear is that we will not have this carefully considered process because of the competitive agenda of the NHS.”

    Training was also the subject of Bertie Leigh's presentation. Mr Leigh, a senior partner for London barristers Hempsons, recently represented Professor Roy Meadow.

    “Many things are getting better, but medical training is getting worse,” he said. “We are getting fewer years of training, fewer hours in each year of training, and emptying each hour of its content.”

    Focusing specialties in fewer hospitals and doing surgical training on models were also compromising training he added.

    “Unfortunately child protection is a diagnosis that cuts across minimum specific training,” he warned.

    The reluctance of junior staff to take on child protection work and the decision of senior doctors to bow out of it came as no surprise to anyone, said Dr Prabhu. Eighty four consultants were reported to the UK's General Medical Council for child protection issues in the past two or three years.

    Both men welcomed Liam Donaldson's plans to reform the role of expert witnesses in the family court, also announced this week.

    “It is a very good idea. We must have a national database of expert witnesses and if we properly train and support these people I think they will come forward,” said Dr Prabhu.

    The Acutely or Critically Sick or Injured Child in the District General Hospital: a Team Response is at Clinical risk management in Paediatrics and Child Health is at

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