Table 1

​Problems in the process of care

Problems in careN
Administration and documentation 3
 Notes or documentation errors2
 Notes or documentation not available1
Communication 18
 Communication failures between staff9
 Communication or handover problems between staff and family4
 Disagreement between staff and family5
Discharge 4
 Inadequate or no handover from hospital to community teams2
 Required equipment not supplied at discharge1
 Unsafe discharge1
Equipment and devices 94
 Incorrect equipment ordered or delivered10
 Equipment not available9
 Problem with ventilator circuit7
 No back-up equipment available6
 Equipment delayed or not delivered4
 Emergency tracheostomy bag not with child4
 Faulty or damaged equipment54
  Suction machine14
  Tracheostomy tube9
  Plastic cuff on tracheostomy device5
  Alarm does not sound when it should have4
  Oxygen saturation monitor2
Information, training and support needs of families 16
 Family carer has not received appropriate training or information5
 Family carer does not follow procedure correctly or goes against advice4
 Concerns relating to family carer’s actions3
 Family carer given inappropriate advice1
 Lack of support for family in the community1
 Child looked after by teenage sibling1
 No training for secondary carers or refresher training for primary carers1
Medications 8
 Medication or prescription errors, for example, dose errors, missed medication7
 Medication unavailable1
Procedures and treatment 91
 Tracheostomy tube come out or is dislodged21
 Protocol not followed correctly15
 Wrong size tracheostomy tube fitted12
 Issues with tracheostomy tapes (too loose/tight, wet or skin damage)10
 Water gets in or nearly gets into tracheostomy9
 Child deteriorating6
 Child gets cut when removing tracheostomy tapes3
 Tracheostomy tube is blocked3
 Problems relating to tracheostomy3
 Wrong ventilator settings1
 Child suctioned at wrong length1
 Child desaturates while being cared for by healthcare assistants1
 Child unable to summon help when needing suctioning1
 Spare tracheostomy tube not clean1
 Inappropriate action by nurse following drop in oxygen saturations1
 Too much water inserted into tracheostomy cuff1
 Forgetting to turn the ventilation on1
 Oxygen cylinder is empty1
Staffing problems 31
 Parents concerned about staff competency12
 Staff asleep while caring for child9
 No staff available6
 Staff do not follow-up problem with family2
 Staff training concerns2
Child behaviour 8
 Child interfering with equipment or care – query self-harm6
 Child abusive to parents or staff2
Parent behaviour 3
 Parents aggressive to staff1
 Missed appointment or reviews1
 Parents refuse specialist care support1
Other 4
 Transport problems4