Progressing your Multi-Agency Children’s Complex Needs Pathways

Cillian has had a varied career in healthcare spanning 15 years, working in Ireland, Australia and the United Kingdom. He is a qualified cardiac and respiratory intensive care nurse and is currently working towards his masters in cardiac nursing. Cillian currently works as the lead Cardiac Adolescent and Transition Clinical Nurse Specialist at Great Ormond Street Hospital. This role involves working with adolescents with congenital heart disease and preparing them for transferring to adult care, teaching them the importance of long term follow-up and a multitude of self-management skills. Cillian has personal knowledge of this subject also, as he is a lifelong patient, born with congenital heart disease himself, he draws upon his own experiences of transitioning from paediatric to adult care to try improve transition for all the patients in his care.

Siobhan has been a Registered Children’s Nurse since 1997 and has always had a special interest in nursing children and young people with very complex health needs.  She has a Specialist Practice Qualification in Community Children's Nursing and also a qualified Practice Teacher.  In her current role she is responsible for assurance and leadership of SEND Health, Children's and young people’s NHS Continuing Care, Children's Transforming Care and other children's complex support needs in Cambridgeshire and Peterborough.

Siobhan has undertaken training in practice development with the Foundation of Nursing Studies and use quality improvement methodology to lead improvements in patient experience and patient safety.

Her most fundamental belief is the importance of practicing person centredness in how she thinks and act- No-one knows what it is like to walk in another person’s shoes.  Listening to understand, compassion, courage and commitment are the values that Siobhan strives to uphold in everyday work for the children, young people and families of Peterborough and Cambridgeshire.

Experience in Safeguarding: I have worked in Safeguarding for over 7 years in acute London Trusts. I have extensive experience in leading safeguarding services. I have completed project work for HEE, NHSEI and train on safeguarding nationally for different CCGs as part of my other work. I have completed legal training for expert witness reports and completed work in this area as a result in safeguarding cases. I have also completed safeguarding experience internationally with Seattle Children’s’ Hospital.

Key interests are: Neglect, Medical Abuse by Carers/FII, Adolescent Safeguarding, Improvement of Safeguarding Processes to support professionals and Safeguarding Training of professionals.

Megan has been a registered learning disability nurse since 2021 and was a student throughout much of the pandemic. Throughout Megan’s training, she was always especially enjoyed working with children and young people with learning disabilities and their families. Megan gained a post within the Health Action Team in the health board and her manager offered her a new role of working with young people with complex health needs and their families to support them through the transition process to adult services.

Megan contacted families of young people with complex needs and asked them their opinion on the transition process. Much of the feedback was unfortunately negative, with most of the families saying the lack of communication regarding transition was where there needed to be the most improvement.

Megan liaised with Eden Carlisle (Children’s Community Nurse – Lead in Transition). Together they discussed setting up a nurse led transition clinic so that young people and their families can come to discuss transition. They liaised with Nerys, the health lead in the social care team to ensure that there could be someone with knowledge on the social side of transition attending the clinics. They created a transition passport for the young people and their families and this is shared with relevant adult professionals. They also put together a transition pack which is sent to families after the clinic. The pack includes information on advocacy, finance and benefit advice, information on the community learning disability team and the learning disability liaison service, information regarding annual health checks and all relevant contact details.

Megan and Eden have created a pathway for transition and are keen to develop a policy and guidelines for the health board.

Megan believes that transition should not only be individualised but totally family centred and is confident that effective communication is key to a smooth and robust transition for young people and their families. 

Maria qualified as a nurse in 1996 from the second intake of Project 2000 nurses in Hertfordshire at the age of 29 and considered a mature student. Her first Band 5 post was at the Luton & Dunstable hospital on Squirrel ward looking after 0-3 year olds. In 1999 after working across the whole of the paediatric unit in Day surgery and PAU she became a Band 6 sister back on Squirrel ward. In total Maria was at the L&D for 11 years.

In 2007 she moved as a family to Cambridge, and started work in the Rosie Neonatal unit at Addenbrookes where she undertook my Specialist care of the New-born and Neonatal Intensive care courses. After 18 months Maria realised that Neonates was not for her and moved to a Junior Sister post on ward C3 which was 0-3’s again.

Maria had always passionately believed that children are best looked after in their own home environment whenever possible and in 2014 was lucky enough to get her dream job of a post in the CCN team in Cambridgeshire.

In September 2015 Maria was offered the opportunity to undertake the Community Specialist Practice Degree at the University of Hertfordshire. This improved her understanding of the logistics of the NHS and enabled her to develop leadership skills. Maria returned to her CCN team in Sept 2016 and in January 2017 took on my Band 7 Role as Lead of the CCN team. Maria has an amazing team of CCN’s who cover the whole of Cambridgeshire, who are busy looking at how to develop the team and move forward with exciting new workstreams and opportunities.