Tony Jackson Memorial Prize - prize winner and finalists 2017

We were pleased to award the 2017 Tony Jackson Memorial Prize to Dr Esther Westwood, for her highly innovative and moving presentation. Delivered in verse, the text and accompanying slides are available to view below. Read on for the abstracts of all four finalists.

Prize winner! Difficult decisions in different settings - Esther Westwood

Prize-winning slides (PDF, 5.2 MB)

Prize-winning Presentation (Verse) (PDF, 98.8 KB)

Spending part of my elective in a developing country and part in a developed country forced me to consider the uncomfortable situation in paediatrics of deciding when to withhold treatment.

I spent the first part of my elective in Zambia, in a rural mission hospital. During my first week a 14 month old boy was brought by in his family – unconscious, with a high fever. When we received him, he started seizing and was quickly diagnosed with cerebral malaria using a rapid diagnostic test. He required brief ventilation with a bag-valve mask and although the seizures were controlled with midazolam and phenobarbital, he did not regain consciousness.

A pragmatic discussion about planning for an arrest resulted in the decision that he was not for intubation – as he would require someone to ventilate him continuously (the hospital had no ventilator). He died later that night.

The second part was spent in the Paediatric and Neonatal Intensive Care Units at Great Ormond Street Hospital. There were many children there with complex medical conditions, some from birth, that would mean they would be dependent lifelong on sophisticated medical intervention.

I couldn't help but think of the infant from Zambia, and what his treatment would likely have been had he been in the UK. He would have been admitted to a paediatric A&E, with a large, competent team to treat him. He would have been given phenytoin to terminate his seizures. His likely profound anaemia would have been corrected by a readily available blood transfusion. Had he needed intubation, he would have been ventilated. If he had recovered, but was one of the 5-30% of children with neurological sequelae, he would have had community support and follow up for his disability.

However, as I researched I was forced to acknowledge that his outcome would very likely still been poor. Which brought me to the consideration of the ethics of treating, and not treating.

The ethical considerations in Zambia are predominantly ones of justice – the infant could not be hand-ventilated by someone indefinitely: it would mean one less person to care for the 120 other patients. In the UK, justice pales compared to beneficence, and beneficence is measured in quality of life, which often in paediatrics, is not fully realised until the child grows up. My big questions as a result of this are how much those considerations of justice and quality of life impact our treatment decisions, particularly as developments ensure that it is possible to prolong life in chronic conditions.

Just because we can do more, should we do more? And as justice is a less immediate consideration in our relatively wealthy country, should we strive to consider it more? Although I am a long way off making these decisions, I resolve to consider these difficult questions more often – and at the very least, be grateful to be from a country where decisions are not often made for us by a lack of resources.

The power of emotions: lessons learnt from children at an Australian hospice - Camille Kostov


  1. Gain experience in caring for children with complex healthcare needs
  2. Have exposure to end of life care
  3. Assist with sibling days and bereavement workshops


Six weeks spent volunteering at a children’s hospice in Melbourne, Australia, caring for children with life-threatening illnesses and providing support for families. The children had a wide range of cognitive impairments and physical disabilities. Many of the conditions I saw were very rare, including genetic and mitochondrial diseases. The daily routine included bathing, feeding, playing and therapy sessions.

I assisted with admissions and discharges, dispensing medications, and attended home visits for new referrals to the hospice. Whilst helping at a day camp for siblings of children with life-threatening illnesses, a ceremony was held for bereaved children to light a candle and commemorate their deceased brother or sister.


It is impossible to quantify or to list everything that I learnt from my time at the hospice. I gained a lot of experience in nutrition, especially in percutaneous endoscopic gastrostomy (PEG) feeding, and in managing children with intractable seizures. My confidence in discussing death and end of life care with children and parents increased. Working with carers and nurses showed me, to some extent, just how much input a person with complex health needs requires, helping me to understand the challenges that families face when caring for a dependent child.

Despite all this, what struck me most in the longer term is the journey that I went through in discovering the strength that emotions can play when caring for sick children and their families. Supporting a mother through the first time in eleven years that she left her sons side showed just how vulnerable parents caring for children with complex health needs are. Furthermore, I realised that although we want to protect our patients at all times, everyone, even children, need to know that it is okay to be sad. At the bereaved siblings day I witnessed children having a safe space to express their emotions, and feeling supported to do so. It was such a powerful thing to be a part of and something that will stay with me for the entirety of my career.

Through watching the staff at the hospice deal with these experiences I saw that the kindness and compassion they expressed through their own emotions provided huge amounts of support to patients and families.

Impact on clinical practice

Sharing your own emotions as a professional, within the appropriate context and boundaries, can show that you are human, and can be a reassuring and touching thing for patients and families. Whilst in practice this is a complex and controversial area, I do believe that emotions can be a really powerful thing, and it is certainly something that I will continue to reflect on throughout my career and that all healthcare professionals should lend consideration to in their daily practise.

After all, we are human too.

Research in children: why we must rise to the challenge - Kate McGraw-Allen

Aims and objectives: To discuss the importance and challenges of research in children.

As an undergraduate I undertook a research project exploring the role of bioelectrical impedance (BI) in both the assessment of nutritional state and its role as a prognostic marker in children undergoing cardiac surgery. The aim was to understand the process of research. Through this experience I learnt not only about the challenges of undertaking research in children, but also came to appreciate its importance. 

Although the measurement of BI is a non-invasive technique, a detailed submission for ethical approval was required. The time taken to complete this and make the necessary modifications to the original submission delayed the onset of the research, a frustration experienced by many researchers.

Despite good intentions for collecting high quality data I found there was often a conflict between clinical and research priorities resulting in a need to take measurements opportunistically and not always according to the recommended protocol. The quality of BI data relied upon adapting the electrodes for use in children of different sizes and also ensuring adequate electrical contact was maintained, which could be lost with movement.
In small children avoiding movement errors was often easier said than done. A method was developed for detecting invalid results; this revealed a high proportion of measurements obtained needed to be discarded.

Despite the challenges it is important to undertake research in children. Beginning with a systematic review of the literature I was shocked to discover how little information was available on children compared to adults. For example, despite the wide use of BI in children, normative data is available only for adults. And yet it is clear that poor nutritional status affects not only children with congenital heart disease but also with a wide range of other chronic childhood conditions, in which it adversely affects their outcome.

Now I am working as an FY1 on a paediatric ward I have noticed that, as healthcare professionals, we are very protective of children and are often reluctant to invite their participation in research. However, a number of the parents consenting for their children to participate in the study, all of whom were very stressed and many with a child with a poor prognosis, were very eager to participate in the research ‘to help others in a similar situation’. This altruism emphasized to me the need for ethically and scientifically robust research to be undertaken in children; it is not enough to rely on data collected from adults.

Whilst not all doctors will become research leaders, it is important for all of those involved in the care of children to understand and facilitate research to provide clinicians with the strong evidence base needed to provide optimal care for the children of the future. Within clinical practice I have found using guidelines invaluable prior to availability of a senior review, as I am relatively inexperienced. The presence of these up to date guidelines would not be possible without the research that underpins them.

My elective in Guyana: where privacy is a luxury - Srividhiya Sriskandakumar

My main objective was to explore the compromises made to facilitate public care, and its differences to private health in a developing country such as Guyana. Furthermore, I wanted to build on my clinical experience by understanding the value of maintaining privacy during a paediatric consultation.

Due to Guyana’s poor health infrastructure, there is no general practitioner, instead children visit a walk-in clinic at Georgetown Public Hospital (GPH). Families queued from 8am for clinic to start at 9am, consisting of up to thirty appointments. Two junior doctors, two nurses and myself were placed in one cramped consulting room, where three consultations occurred in parallel. This was a stark difference to the private clinic, where the setup was as expected in modern medicine, one-to-one pre-booked appointments with myself and the consultant only.

There was no privacy or seclusion at GPH. The disbelief of multiple examinations happening in the same room was masked by the shock of how normal this was. Parents and colleagues could overhear consultations; other children could watch in on examination and there was a lack of discretion. By compromising privacy, GPH provides the only free clinic which accommodates children from Georgetown and its neighbouring cities, balancing the needs of those who depend on public health between the few available doctors.

When examining children, an invasion of their privacy can provoke emotional reactions, causing embarrassment and anxiety. This can be alleviated with early communication between the physician, parent and child regarding the aims of the examination. Parents who attended were aware of the constraints of public services, therefore the standards expected were lower. However, this does not mean that privacy had to be neglected altogether.

During my time, I tried my best to ensure privacy. This was achieved by doing what needed to be done versus what I had been taught to do. I felt children were vulnerable because of the audience around them, overcoming this by employing the parent to provide comfort. By succinctly describing what I was about to do, I engaged better with children and made them more compliant to examination.

By focussing my attention on one child and their complaint, I could provide a certain degree of isolation which made the appointment more comfortable for myself and the child.

Privacy is a luxury of medicine in the developed world that we under-appreciate, expanding much further than just confidentiality, going on to include dignity and discretion. It can comfort children and help them build trust in us, allowing us to question and examine them openly and trust in the decisions we make on their behalf.

This ensures children grow up to see us as not just their doctor, but someone they can happily confide in. It can facilitate a two-way relationship between the physician and their patient, where even in some of the most constrained environments, any possible privacy can ensure the best healthcare is delivered.