Problems in the process of care
| Problems in care | N |
| Administration and documentation | 3 |
| Notes or documentation errors | 2 |
| Notes or documentation not available | 1 |
| Communication | 18 |
| Communication failures between staff | 9 |
| Communication or handover problems between staff and family | 4 |
| Disagreement between staff and family | 5 |
| Discharge | 4 |
| Inadequate or no handover from hospital to community teams | 2 |
| Required equipment not supplied at discharge | 1 |
| Unsafe discharge | 1 |
| Equipment and devices | 94 |
| Incorrect equipment ordered or delivered | 10 |
| Equipment not available | 9 |
| Problem with ventilator circuit | 7 |
| No back-up equipment available | 6 |
| Equipment delayed or not delivered | 4 |
| Emergency tracheostomy bag not with child | 4 |
| Faulty or damaged equipment | 54 |
| Suction machine | 14 |
| Tracheostomy tube | 9 |
| Tapes | 8 |
| Humidifier | 6 |
| Plastic cuff on tracheostomy device | 5 |
| Alarm does not sound when it should have | 4 |
| Ventilator | 4 |
| Circuit | 2 |
| Oxygen saturation monitor | 2 |
| Information, training and support needs of families | 16 |
| Family carer has not received appropriate training or information | 5 |
| Family carer does not follow procedure correctly or goes against advice | 4 |
| Concerns relating to family carer’s actions | 3 |
| Family carer given inappropriate advice | 1 |
| Lack of support for family in the community | 1 |
| Child looked after by teenage sibling | 1 |
| No training for secondary carers or refresher training for primary carers | 1 |
| Medications | 8 |
| Medication or prescription errors, for example, dose errors, missed medication | 7 |
| Medication unavailable | 1 |
| Procedures and treatment | 91 |
| Tracheostomy tube come out or is dislodged | 21 |
| Protocol not followed correctly | 15 |
| Wrong size tracheostomy tube fitted | 12 |
| Issues with tracheostomy tapes (too loose/tight, wet or skin damage) | 10 |
| Water gets in or nearly gets into tracheostomy | 9 |
| Child deteriorating | 6 |
| Child gets cut when removing tracheostomy tapes | 3 |
| Tracheostomy tube is blocked | 3 |
| Problems relating to tracheostomy | 3 |
| Wrong ventilator settings | 1 |
| Child suctioned at wrong length | 1 |
| Child desaturates while being cared for by healthcare assistants | 1 |
| Child unable to summon help when needing suctioning | 1 |
| Spare tracheostomy tube not clean | 1 |
| Inappropriate action by nurse following drop in oxygen saturations | 1 |
| Too much water inserted into tracheostomy cuff | 1 |
| Forgetting to turn the ventilation on | 1 |
| Oxygen cylinder is empty | 1 |
| Staffing problems | 31 |
| Parents concerned about staff competency | 12 |
| Staff asleep while caring for child | 9 |
| No staff available | 6 |
| Staff do not follow-up problem with family | 2 |
| Staff training concerns | 2 |
| Child behaviour | 8 |
| Child interfering with equipment or care – query self-harm | 6 |
| Child abusive to parents or staff | 2 |
| Parent behaviour | 3 |
| Parents aggressive to staff | 1 |
| Missed appointment or reviews | 1 |
| Parents refuse specialist care support | 1 |
| Other | 4 |
| Transport problems | 4 |