As low as reasonably practicable (ALARP): a moral model for clinical risk management in the setting of technology dependence.

Children dependent on life-prolonging medical technology are often subject to a constant background risk of sudden death or catastrophic complications. Such children can be cared for in hospital, in an intensive care environment with highly trained nurses and doctors able to deliver specialised, life-saving care immediately. However, remaining in hospital, when life expectancy is limited, can considered to be a harm in of itself. Discharge home offers the possibility for an improved quality of life for the child and their family but comes with significant medical risks.When making decisions for children, two ethical models predominate, the promotion of the child's best interests or the avoidance of harm. However, in some circumstances, particularly for children with life-limiting and/or life-threatening illness, all options may be associated with risk. There are no good options, only potentially harmful choices.In this paper, we explore decisions made by one family in such circumstances. We describe a model adopted from risk management programmes beyond medicine, which offers a potential framework for identifying risks to the child that are morally permissible. Some risks and harms to a child, not ordinarily permitted, may be acceptable when undertaken in the pursuit of a specified desired good, so long as they are as low as reasonably practicable.

British Thoracic Society Paediatric Pneumonia Audit: a review of 3 years of data.

The British Thoracic Society (BTS) guidelines for the management of community-acquired pneumonia in children are used as the audit standard for the annual BTS Paediatric Pneumonia Audit. This report examines 3 years of data from this national audit, highlighting trends in clinical practice and the impact of the 2011 revisions to the BTS guidelines. The findings suggest an over-reliance on investigations to diagnose pneumonia and underuse of oral antibiotics, particularly amoxicillin. There is inappropriate use of chest physiotherapy, outpatient appointments and repeat chest x-rays. Increasing adherence to the BTS guidelines would improve care and also preserve valuable secondary care resources.