Recurring concern

Unreliable neonatal infection guidance

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First reported 6 Jan 2015•Latest report 12 Aug 2023

Definition

What this concern includes

Includes failures in explicitly neonatal infection guidance and its dedicated implementation, including inconsistency with NICE or best practice, conflicting neonatal scoring or guidance systems, unclear infection thresholds and failure to ensure responsible clinicians know and apply the relevant guidance.

Not included

  • Excludes general sepsis recognition or treatment failures where neonatal infection guidance is not the deficient control.
  • Excludes guidance for meningitis, allergy, anticoagulation or other conditions unless the assertion specifically concerns neonatal infection guidance.
  • Excludes generic clinical training, communication or documentation deficiencies unless they directly impair the clarity, consistency or application of neonatal infection guidance.
  • Excludes failures to follow clear and understood guidance where the guidance itself and its dissemination are reliable.
Reports
3

Distinct published reports

Individual concerns
4

A report can raise multiple concerns

Date range
2015–2023

First to latest report issue date

Stated actions
4

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

NHS England2
British Association of Perinatal Medicine1
Department of Health and Social Care1
NHS Cornwall and the Isles of Scilly Integrated Care Board1
Royal College of Paediatrics and Child Health1
Royal Cornwall Hospital1
South London Healthcare NHS Trust1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Inner South London

    AI-generated summary

    Baby Isabela Suciu · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Baby Isabela Suciu was born in hospital and later suffered a cardiac arrest at home after feeding; she did not regain consciousness and died in hospital. Concerns included the failure to escalate low temperatures for paediatric review or start antibiotics, amid conflicting Kaiser Permanente and NICE guidance. The report identified a continuing risk of confusion and avoidable delay in other neonatal units, although the omission was not shown to have caused Isabela’s death.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to provide clear and consistent guidance when applying the Kaiser Permanente Score and NICE guidance

    Wider context from the report

    “If the Newborn Early Warning Trigger and Track score had been followed the hypothermia would have triggered escalation by the midwife to paediatricians at 02.00 when the temperature was 36.3. Paediatrician ████████, advised that the KP score would not alter then, but at 06.20, the temperature of 36.2 should have triggered starting antibiotics. There was agreement amongst experts that antibiotics should have been started at 06.20 on 3rd of November. It is accepted by the doctors and Trust that this should have happened and did not because of conflict between the Kaiser Permanente Score and the NICE guidance. Whilst this omission was not shown to have caused Isabela’s death, it creates a possible risk for other hospitals using the KP scale. Expert microbiologist ███████████ informed the court that it was not that the KP scale was inferior to NICE recommendations, but rather that there is a risk as the threshold for antibiotics is different, that doctors will think the KP score is gospel and not look at the patient as a whole and therefore miss clinical signs which should trigger starting antibiotics. ████████████████, consultant neonatology expert opined that the evidence for the use of KP pathway was thin, and it was better to follow NICE guidance as KP should only be used as part of an overall assessment. Expert neonatologist █████████████ agreed saying that the use of two guidelines was confusing. ████████ expert opinion was that there was a risk of deaths in other neonatal units and that the expert was not sure how well known the differences and apparent conflict in applying the guidelines was known. The Trust have taken a number of steps to address the risk, but there appears to remain the opportunity for confusion as the revised Newborn Early Warning Trigger and Track score indicates a different response from KP, when late onset symptoms occur after an asymptomatic period, creating a risk of avoidable delay. ”

    Source location

    Baby Isabela Suciu · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to use the Kaiser Permanente Score as part of an overall assessment of the patient

    Wider context from the report

    “If the Newborn Early Warning Trigger and Track score had been followed the hypothermia would have triggered escalation by the midwife to paediatricians at 02.00 when the temperature was 36.3. Paediatrician ████████, advised that the KP score would not alter then, but at 06.20, the temperature of 36.2 should have triggered starting antibiotics. There was agreement amongst experts that antibiotics should have been started at 06.20 on 3rd of November. It is accepted by the doctors and Trust that this should have happened and did not because of conflict between the Kaiser Permanente Score and the NICE guidance. Whilst this omission was not shown to have caused Isabela’s death, it creates a possible risk for other hospitals using the KP scale. Expert microbiologist ███████████ informed the court that it was not that the KP scale was inferior to NICE recommendations, but rather that there is a risk as the threshold for antibiotics is different, that doctors will think the KP score is gospel and not look at the patient as a whole and therefore miss clinical signs which should trigger starting antibiotics. ████████████████, consultant neonatology expert opined that the evidence for the use of KP pathway was thin, and it was better to follow NICE guidance as KP should only be used as part of an overall assessment. Expert neonatologist █████████████ agreed saying that the use of two guidelines was confusing. ████████ expert opinion was that there was a risk of deaths in other neonatal units and that the expert was not sure how well known the differences and apparent conflict in applying the guidelines was known. The Trust have taken a number of steps to address the risk, but there appears to remain the opportunity for confusion as the revised Newborn Early Warning Trigger and Track score indicates a different response from KP, when late onset symptoms occur after an asymptomatic period, creating a risk of avoidable delay. ”

    Source location

    Baby Isabela Suciu · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review and update neonatal hypoglycaemia and Kaiser Permanente sepsis assessment guidelines in line with NICE guidance.

    Verbatim wording from the response

    “The Neonatal service leads have reviewed and updated the following Trust guidelines to be reflective of practice in line with NICE guidance for the care of newborn babies:”

    Source location

    Response from Lewisham and Greenwich
    Page 2 · response
    Published 15 September 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Implement updated neonatal paper notes incorporating NEWTT2, Kaiser pathway and treatment escalation information, with supporting staff teaching.

    Verbatim wording from the response

    “The Trust has updated its paper neonatal notes, which includes the updated NEWTT2 chart, and these were ratified at the Women’s, Sexual Health and Neonates Divisional Governance meeting in October 2023. They were subsequently printed by the Trust Reprographics team and are being implemented with additional teaching and support from practice development midwives throughout both maternity services.”

    Source location

    Response from Lewisham and Greenwich
    Page 2 · response
    Published 15 September 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Add frequently asked questions clarifying the distinction between tools for determining additional observations and NEWTT2 for tracking observations.

    Verbatim wording from the response

    “While the two tools mentioned above are used to determine which babies need additional observations, the NEWTT2 chart can then be used to track the observations and provides recommendations on escalation where necessary. We do have material on our website to support the use of the NEWTT2 chart and we will add a section to our frequently asked questions to ensure that staff are clear on the difference between tools for determining which babies need additional observations and the NEWTT2 tool for tracking those observations. We will also use a safety notice to our members to remind them of appropriate use of each of these tools.”

    Source location

    Response from Royal College of Paediatrics and Child Health
    Page 2 · response
    Published 15 September 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Issue a safety notice reminding members about appropriate use of the neonatal sepsis and NEWTT2 tools.

    Verbatim wording from the response

    “While the two tools mentioned above are used to determine which babies need additional observations, the NEWTT2 chart can then be used to track the observations and provides recommendations on escalation where necessary. We do have material on our website to support the use of the NEWTT2 chart and we will add a section to our frequently asked questions to ensure that staff are clear on the difference between tools for determining which babies need additional observations and the NEWTT2 tool for tracking those observations. We will also use a safety notice to our members to remind them of appropriate use of each of these tools.”

    Source location

    Response from Royal College of Paediatrics and Child Health
    Page 2 · response
    Published 15 September 2023

    Open published response

  2. Cornwall and Isles of Scilly

    AI-generated summary

    Charlie Mark Jermyn · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Charlie Jermyn was born at home on 9 May 2015 and developed sleepiness, feeding difficulty and possible respiratory distress. He stopped breathing during a routine visit the following day and died in hospital despite resuscitation attempts. The principal concerns were delayed recognition and referral for suspected sepsis, inadequate telephone triage and recording, insufficient observations, and wider shortcomings in midwifery guidance, equipment and training.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure of neonatal infection guidelines to be known and consistent with NICE guidance

    Wider context from the report

    “8. The red flag signs for sepsis (in this case sleepy, possible respiratory distress (grunting) and difficulty in feeding) were overlooked resulting in a fatal delay in referral to specialist hospital support/treatment. Identification of sepsis in new born babies is difficult and the staff and Trust should have had in place a systemic, rigorous and regular training in this area. The Trust's own clinical guidelines for the Prevention, Diagnosis and Treatment of Early Onset Neonatal Bacterial Infection, were not known to the midwives at the inquest. The Expert Midwife gave the opinion that the RCHT Trust guidelines were not consistent with the NICE guidance or best practice on this matter (page 14). In particular it was noted that capillary re-fill time should be undertaken and recorded in cases of suspected sepsis. ”

    Source location

    Charlie Mark Jermyn · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. North London

    AI-generated summary

    Carla London · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Carla London was born extremely premature and died in hospital on 26 April 2011 after rapidly deteriorating following treatment for suspected sepsis. The report raised concerns about the need for NICE guidance on late-onset sepsis in babies weighing under 1500 g and research into HeRO or other infection-monitoring systems.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to consider NICE guidance on late onset sepsis in babies under 1500 g

    Wider context from the report

    “That coroner shares the concerns expressed by the independent expert that consideration should be given to NICE guidance on late onset sepsis in under 1500 gms babies and that and for research in to HeRO or other infection monitoring systems. ”

    Source location

    Carla London · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Local maternity and neonatal providers determine how services are delivered in their areas, having regard to NICE guidance.

    Verbatim wording from the response

    “Local maternity and neonatal care providers determine how best to deliver services in their area. In doing so we would always expect them to give due regard to NICE guidance.”

    Source location

    2015-0003-Response-by-Department-of-Health
    Page 2 · response
    Published 6 January 2015

    Open published response
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Data last updated 7 September 2026