Datix-style clinical & operational incident reporting
1
of 7 total YTD
1
Reported to ICB / external
1
HSE notifiable incidents
1
Drug / device defects
Reporter
Sarah Mitchell · Emergency Care Assistant
Reported at
2026-04-30 15:02
Patient involved
Yes
Staff involved
S003 Sarah Mitchell · S002 James Harrison · S004 Daniel Okafor
Description
Paediatric out-of-hospital cardiac arrest (4yo male). Bystander CPR ongoing on arrival. ROSC achieved at 11 minutes; transferred to Royal Surrey PICU. Initial rhythm asystole — defibrillator pads applied at 0.7 minutes (delayed by approx 90s while paediatric pads located).
Immediate Actions
Pads relocated to a single, quick-access pouch on Romeo 1 immediately post-call. All Trust paediatric pad locations re-checked same shift. Crew offered immediate hot debrief; TRiM enrolment confirmed.
Investigation
Lead
Dr Priya Sharma (Medical Director)
Method
patient safety incident
Started
2026-05-01
Due
2026-06-12
Findings: Provisional: contributory factor — paediatric pads stored in a separate sealed bag in equipment locker, not the main resus drawer. No clinical-care omission identified. Full review pending PICU outcome.
Root cause: Equipment storage convention inconsistent across fleet.
Duty of Candour
Discharged 2026-05-02
Dr Priya Sharma