27 Jul 2018 Mrs Natalie Billingham · Prevention of Future Deaths report Black Country
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Concerns raised 1
Failure to recognise the development of sepsis View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Mrs Natalie Billingham · 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
Mrs Natalie Billingham was admitted to hospital with worsening foot pain, later developed necrotising fasciitis, underwent emergency surgery including a through-knee amputation, and died on the evening of 2 March 2018. The report identified concerns about inadequate communication and delays in reviewing abnormal blood results, recognising sepsis, and administering antibiotics.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to recognise the development of sepsis
Wider context from the report “1. Evidence emerged during the inquest that there was inadequate communication and delays in assessing the blood results when available. There were also missed opportunities for administering antibiotics at an earlier stage and recognising the development of sepsis .
” Source location Mrs Natalie Billingham · Prevention of Future Deaths report
Open source report
11 Jul 2018 Rita Elizabeth GILES · Prevention of Future Deaths report Brighton and Hove
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Concerns raised 1
Failure to recognise the urgency of treatment for septic patients View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Rita Elizabeth GILES · 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
Rita Elizabeth GILES underwent an endoscopic retrograde cholangiopancreatography after delays and was reported not to have recovered, dying a few days later. The concerns included unnecessary transfers without supporting paperwork, failure to follow the Trust’s Transfer Policy, limited ERCP capacity, and failure to recognise the urgency associated with her sepsis; it was suggested that earlier transfer to the Royal Sussex County Hospital might have enabled urgent treatment.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to recognise the urgency of treatment for septic patients
Wider context from the report “(1) Unnecessary transfers to and from the Princess Royal Hospital with no supporting paperwork.
(2) The Trust’s own Transfer Policy not adhered too in any respect.
(3) Delay in her endoscopic retrograde cholangiopancreatography ERCP until she was so ill that it needed to be done on the CEPOD list under general anaesthetic and required ICU support. This lady never recovered from this procedure and died a few days later.
(4) At Inquest it was explained to me that there are only three people in the Trust that can carry out ERCP work, they have one list each a week, lists are only on Mondays, Wednesdays and Fridays. The lists seem to be booked well in advance so there is little or no resource for the patient who comes in as Miss Giles did with an urgent requirement.
There was a failure to appreciate that as she was already septic when she came in the matter was urgent .
From the Inquest it appeared that the Princess Royal Hospital was not the right place for her to be, there is argument to suggest that she should have been transferred early to the Royal Sussex County Hospital in Brighton and presumably if she needed urgent treatment she could have had it. Surely, the lists are designed to accommodate the patients not the other way round.
” Source location Rita Elizabeth GILES · Prevention of Future Deaths report
Open source report
Concerns raised 2
Failure to follow Sepsis Six care bundles in accordance with guidelines View source Failure to identify red flag signs of sepsis View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
the Shrewsbury and Telford Hospital NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 7
the Shrewsbury and Telford Hospital NHS Trust
Introduce a bespoke sepsis trolley in the Surgical Assessment Unit for timely treatment.
View source
the Shrewsbury and Telford Hospital NHS Trust
Deliver sepsis education across both Emergency Departments, including recognition, screening, Sepsis Six and reference-card reinforcement.
View source
the Shrewsbury and Telford Hospital NHS Trust
Review Emergency Department trolleys and assess a trial trolley containing equipment, antibiotics and fluids for immediate sepsis care.
View source
the Shrewsbury and Telford Hospital NHS Trust
Develop a Patient Group Directive enabling specified senior nurses to deliver sepsis fluids and antibiotics within one hour when a doctor is unavailable.
View source
the Shrewsbury and Telford Hospital NHS Trust
Work with medical teams to train all doctors in sepsis recognition and treatment.
View source
the Shrewsbury and Telford Hospital NHS Trust
Create and implement a revised sepsis screening tool in the Surgical Assessment Unit.
View source
the Shrewsbury and Telford Hospital NHS Trust
Use Sepsis Champions as Emergency Department links to support staff education with the Critical Care Outreach Team.
View source See 4 more actions
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Patricia Violet PALIN · 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
Patricia Violet PALIN died on 2 October 2017 after presenting to hospital with sepsis and kidney damage. The report describes delayed recognition and treatment, including delayed antibiotics, absence of oxygen administration, failure to remove leg dressings for examination, and failure to follow sepsis guidelines. Concerns also included limited access to GP records, insufficient A&E doctor cover, and an unavailable prescribed antibiotic.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to follow Sepsis Six care bundles in accordance with guidelines
Wider context from the report “4. Whilst there was a general awareness of the dangers of sepsis from the Shropdoc and Hospital witness evidence;
a. Red flag signs of sepsis were missed.
b. Leg bandages were not removed to allow full top to toe examination.
c. Sepsis six care bundles were not followed in accordance with guidelines .
” Source location Patricia Violet PALIN · Prevention of Future Deaths report
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 identify red flag signs of sepsis
Wider context from the report “4. Whilst there was a general awareness of the dangers of sepsis from the Shropdoc and Hospital witness evidence;
a. Red flag signs of sepsis were missed .
b. Leg bandages were not removed to allow full top to toe examination.
c. Sepsis six care bundles were not followed in accordance with guidelines.
” Source location Patricia Violet PALIN · Prevention of Future Deaths report
Open source report
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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 Introduce a bespoke sepsis trolley in the Surgical Assessment Unit for timely treatment.
Verbatim wording from the response “• New Sepsis Trolley – the SAU team introduced a bespoke sepsis trolley to store all of the items required to provide timely treatment for patients who are diagnosed with sepsis generating greater efficiency and reliability based on ‘set up reduction’.” Source location 2018-0183-Response-by-Shrewsbury-and-Telford-Hospitals-NHS-Trust
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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 Deliver sepsis education across both Emergency Departments, including recognition, screening, Sepsis Six and reference-card reinforcement.
Verbatim wording from the response “However, given that Mrs Palin’s delays were based in the Emergency Department I wish to you update you on the work which has taken place and the on-going plans to improve sepsis care in ED specifically. Our Critical Care Outreach Team commenced a programme of sepsis education in both Emergency Departments, as of last week; to date 20 staff have been trained. The education is targeting all clinical staff in the department; however this is limited to availability of staff due to work load. The training sessions are taking place daily, 7 days a week. The feedback has been really positive from all staff. The areas covered within the teaching session are recognition using visual signs, as well as recognition using the Sepsis screening tool. The team then look at the Sepsis Six pathway in detail and discuss the importance of delivering this within the one hour time frame.” Source location 2018-0183-Response-by-Shrewsbury-and-Telford-Hospitals-NHS-Trust
Open published response
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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 Emergency Department trolleys and assess a trial trolley containing equipment, antibiotics and fluids for immediate sepsis care.
Verbatim wording from the response “Alongside this we are reviewing the trolleys in the department, with the possibility of trialling a trolley that will allow for us to put everything into the trolley for immediate care of the septic patient, this includes antibiotics and fluids. The existing trolley in place does not carry everything required for immediate care.” Source location 2018-0183-Response-by-Shrewsbury-and-Telford-Hospitals-NHS-Trust
Open published response
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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 Develop a Patient Group Directive enabling specified senior nurses to deliver sepsis fluids and antibiotics within one hour when a doctor is unavailable.
Verbatim wording from the response “We are also developing a Patient Group Directive which will allow Senior Band 5 Nurses and Band 6 Nurses to deliver the fluids and antibiotics within the one hour required time frame in the event that a Doctor is not available to meet the demands of the one hour time frame. This is a huge step for us and one that has been welcomed by all of the nursing staff within the ED. Both ED’s have Practice Education Nurses who will continue to ensure all staff are up to date with their sepsis training.” Source location 2018-0183-Response-by-Shrewsbury-and-Telford-Hospitals-NHS-Trust
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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 Work with medical teams to train all doctors in sepsis recognition and treatment.
Verbatim wording from the response “Sepsis Champions have also been chosen to be a link within the ED, and they will work closely with the Critical Care Outreach Team to continue the education and provide support for all staff within the ED. The Team are also in the process of working with the Medical Teams to ensure that all the Doctors are trained in Sepsis recognition and treatment.” Source location 2018-0183-Response-by-Shrewsbury-and-Telford-Hospitals-NHS-Trust
Open published response
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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 Create and implement a revised sepsis screening tool in the Surgical Assessment Unit.
Verbatim wording from the response “The Root Cause Analysis was shared with the staff involved in order for lessons to be learnt by the individuals involved in Mrs Palin’s care. This was reflected by Dr ████████ who attested to this in the Inquest hearing. In addition to this the Trust has carried out work on Sepsis and much more is planned through the Trust. In the last few years our organisation partnered with Virginia Mason Hospital in America, in order to improve patient safety and care. As part of this, one of the Value Streams has focused on Sepsis and improving care for patients with this condition. Some of the improvements which are being rolled out include:” Source location 2018-0183-Response-by-Shrewsbury-and-Telford-Hospitals-NHS-Trust
Open published response
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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 Use Sepsis Champions as Emergency Department links to support staff education with the Critical Care Outreach Team.
Verbatim wording from the response “Sepsis Champions have also been chosen to be a link within the ED, and they will work closely with the Critical Care Outreach Team to continue the education and provide support for all staff within the ED. The Team are also in the process of working with the Medical Teams to ensure that all the Doctors are trained in Sepsis recognition and treatment.” Source location 2018-0183-Response-by-Shrewsbury-and-Telford-Hospitals-NHS-Trust
Open published response
21 Jul 2017 James David Allbones · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 1
Failure of the Paediatric team to recognise and act on sepsis red flag signs View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
James David Allbones · 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
James David Allbones, aged five, died from sepsis caused by Influenza B virus infection at Bassetlaw Hospital on 2 March 2016, after being admitted within 12 hours and having been unwell with cough and breathlessness. The report identified concerns that the seriousness of his condition and red-flag signs of sepsis were not recognised, sepsis fluid management was not given, Consultant management and review were limited, and he was not considered early for transfer to a hospital providing Paediatric Intensive Care. Further concerns included paediatric staffing, handover arrangements, and communication about deteriorating children.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of the Paediatric team to recognise and act on sepsis red flag signs
Wider context from the report “That the ‘red flag signs’ of sepsis will not be recognised and acted upon by the Paediatric team unless there is further training and awareness raising. I suggest The Paediatric Consultant team access external training and mentoring by senior colleagues ideally within their Critical Care network.
” Source location James David Allbones · Prevention of Future Deaths report
Open source report
Concerns raised 2
Failure to identify red flag signs of neonatal sepsis View source Failure to undertake and record capillary refill time in suspected neonatal sepsis View source
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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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.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to identify red flag signs of neonatal sepsis
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
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 undertake and record capillary refill time in suspected neonatal sepsis
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
Open source report
18 Mar 2016 Rubana PATHAN · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Failure to disseminate information that toxins can suppress signs of local inflammation in patients at risk of sepsis View source
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Rubana PATHAN · 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
Rubana Pathan was admitted to Homerton University Hospital and was diagnosed with toxic shock syndrome associated with a Staphylococcus aureus infection of an infected breast implant wound. A concern was raised that the absence of pus or localised redness may have contributed to the implant not being recognised as the cause of sepsis, because the responsible toxin can suppress signs of local inflammation.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to disseminate information that toxins can suppress signs of local inflammation in patients at risk of sepsis
Wider context from the report “Although Ms Pathan’s MENTOR breast implant was suspected as being the cause of her sepsis and was removed on the evening of Saturday, 7 November 2015, her surgeon told me at inquest that she still did not believe this to be the cause, because she found no pus or localised redness.
However, one of the treating microbiologists undertook a literature search after Ms Pathan’s death and discovered that the toxin found to be responsible for her illness can supress signs of local inflammation such as the production of pus.
Although this is a rare occurrence, it seems to me that the information could usefully be disseminated among those likely to be caring for patients who may be at risk of developing sepsis , both by the hospital and by the implant manufacturer.
” Source location Rubana PATHAN · Prevention of Future Deaths report
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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 Disseminate the literature search and the need for heightened suspicion of staphylococcal toxic shock syndrome to all Trust doctors.
Verbatim wording from the response “2. I have highlighted the need to have a high index of suspicion for sepsis associated with Staphylococcal Toxic Shock Syndrome, and shared ████████ detailed literature search, with all doctors in the Trust by email.” Source location 2016-0113-Response-by-Homerton-University-Hospital-NHS-Trust
Open published response
Concerns raised 3
Lack of clarity about paediatric sepsis signs and responses View source Lack of paediatric sepsis treatment protocol and guidance View source Unavailability of a paediatric sepsis screening tool View source
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
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Marc Jason Stephen Poole · 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
Marc Jason Stephen Poole, aged 6, was admitted to hospital on 16 May 2015 with suspected infection and died in Sheffield Children’s Hospital on 18 May 2015 from the effects of pneumococcal septicaemia. The report identified concerns about delayed antibiotic treatment, poor communication, inaccurate observation and warning-score recording, inadequate paediatric sepsis guidance, dissemination of medical information, and poor record keeping.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of clarity about paediatric sepsis signs and responses
Wider context from the report “(3) Sepsis in Paediatrics
It is clear that consideration should be given to developing a protocol and guidance for those treating children. A paediatric screening tool needs to be provided. There needs to be clear explanations of the terms septic, sepsis, septic shock, septicaemia, bacteraemia. These terms were used interchangeably. It needs to be made clear to staff the signs they should be looking out for and how these might be responded to.
” Source location Marc Jason Stephen Poole · Prevention of Future Deaths report
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 Lack of paediatric sepsis treatment protocol and guidance
Wider context from the report “(3) Sepsis in Paediatrics
It is clear that consideration should be given to developing a protocol and guidance for those treating children. A paediatric screening tool needs to be provided. There needs to be clear explanations of the terms septic, sepsis, septic shock, septicaemia, bacteraemia. These terms were used interchangeably. It needs to be made clear to staff the signs they should be looking out for and how these might be responded to.
” Source location Marc Jason Stephen Poole · Prevention of Future Deaths report
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 Unavailability of a paediatric sepsis screening tool
Wider context from the report “(3) Sepsis in Paediatrics
It is clear that consideration should be given to developing a protocol and guidance for those treating children. A paediatric screening tool needs to be provided. There needs to be clear explanations of the terms septic, sepsis, septic shock, septicaemia, bacteraemia. These terms were used interchangeably. It needs to be made clear to staff the signs they should be looking out for and how these might be responded to.
” Source location Marc Jason Stephen Poole · Prevention of Future Deaths report
Open source report
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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 and disseminate an agreed paediatric sepsis toolkit across clinical areas.
Verbatim wording from the response “The inquest noted that there was lack of use of the sepsis tool kit and this is of significant concern both to your office as well as the Trust. Since the outcome of the inquest the Trust has worked rapidly to introduce such a tool based on the UK Sepsis Trust tool to which there has been both nursing and medical contribution. I attach the tool which has been agreed, implemented and disseminated in all the clinical” Source location Marc-Poole-Response
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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 Provide multidisciplinary training on paediatric sepsis and unexpected deterioration, including training for medical staff during each house induction.
Verbatim wording from the response “areas. Multi-disciplinary staff development will continue to provide training on sepsis in children and unexpected deterioration in children. This training will include medical staff on induction for each house.” Source location Marc-Poole-Response
Open published response
22 Dec 2015 Shalini GANESH-RAM · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Failure to use the modified obstetric early warning score tool appropriately to identify sepsis View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Shalini GANESH-RAM · 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
Shalini Ganesh-Ram died in the Royal London Hospital on 11 August 2015 after developing Ogilvie’s syndrome following a Caesarean section, which led to a perforated caecum. The concerns included delayed diagnosis of the perforation, delays in CT scanning and surgical consultation, and inappropriate use of the modified obstetric early warning score to identify sepsis.
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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 modified obstetric early warning score tool appropriately to identify sepsis
Wider context from the report “4. Your own serious incident report has already identified other issues around service delivery, most particularly that the modified obstetric early warning score tool was not used appropriately to identify Ms Ganesh-Ram’s sepsis .
” Source location Shalini GANESH-RAM · Prevention of Future Deaths report
Open source report
Concerns raised 2
Failure to use a sepsis screening tool in community healthcare View source Failure to recognise or adopt a UK sepsis clinical toolkit View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
Central Nottinghamshire Clinical Services (CNCS East Midlands Ambulance Service NHS Trust NHS England, Midlands & East (Central Midlands West Leicestershire Clinical Commissioning Group
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 6
East Midlands Ambulance Service NHS Trust
Introduce updated adult and paediatric sepsis screening tools based on Sepsis 6 red flags and the NHS England safety alert.
View source
Central Nottinghamshire Clinical Services (CNCS and West Leicestershire Clinical Commissioning Group
Implement the Sepsis 6 pathway at the Loughborough Urgent Care Centre.
View source
Central Nottinghamshire Clinical Services (CNCS and West Leicestershire Clinical Commissioning Group
Re-issue sepsis patient safety alert guidance to LLR general practices, including access to adult, paediatric and infant screening and action tools.
View source
NHS England, Midlands & East (Central Midlands
Highlight the importance of diagnosing sepsis and using the sepsis screening tool through the local medical committee.
View source
Central Nottinghamshire Clinical Services (CNCS and West Leicestershire Clinical Commissioning Group
Develop an approved system for reviewing and implementing patient safety alerts, with subsequent assurance reporting to the Clinical Governance Committee.
View source
Central Nottinghamshire Clinical Services (CNCS and West Leicestershire Clinical Commissioning Group
Hold a meeting with University Hospitals of Leicester to share sepsis quality-improvement experience and materials and obtain implementation support.
View source See 3 more actions
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AI-generated summary
Caroline Robey · 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
Caroline Robey was a fit 34-year-old working mother who became unwell and attended community healthcare providers on six occasions over five days. She was initially diagnosed with a viral infection and later diarrhoea and vomiting, before being admitted to hospital with suspected sepsis; despite treatment, she died the following day from Group A streptococcal infection and evolving sepsis. The principal concerns were the absence of sepsis screening by community healthcare providers, failure to adopt available sepsis toolkit resources, and inadequate consideration of her repeated attendances.
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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 a sepsis screening tool in community healthcare
Wider context from the report “1. No sepsis screening tool was being used by the community health care providers , and so opportunities were lost to consider a diagnosis of sepsis and refer as an emergency for hospital admission and treatment.
” Source location Caroline Robey · Prevention of Future Deaths report
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 recognise or adopt a UK sepsis clinical toolkit
Wider context from the report “2. A patient safety alert issued 2 September 2014 by NHS England clearly sets out resources available in the provision of a UK sepsis clinical tool kit, but this had not been recognised or adopted by the health care providers involved in this case .
” Source location Caroline Robey · Prevention of Future Deaths report
Open source report
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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 Introduce updated adult and paediatric sepsis screening tools based on Sepsis 6 red flags and the NHS England safety alert.
Verbatim wording from the response “In March 2015 EMAS introduced an updated sepsis screening tool (both adult and paediatric) based upon the Sepsis 6 red flags and NHS England Safety Alert (2014) (appendices 1a and 1b). Prior to this EMAS had in place a generic sepsis screening tool based upon the same features as the updated tool but did not have specific paediatric element included (appendix 2).” Source location ROBEY-Responses
Open published response
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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 the Sepsis 6 pathway at the Loughborough Urgent Care Centre.
Verbatim wording from the response “Please see the enclosed action plan developed by the Loughborough Urgent Care Centre. As you will note, an organisational sepsis policy has been developed and during April and May 2015 all staff at the Loughborough Urgent Care Centre completed a training course in sepsis recognition. In addition, work is currently ongoing at the Loughborough Urgent Care Centre to implement the sepsis6 pathway.” Source location ROBEY-Responses
Open published response
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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 Re-issue sepsis patient safety alert guidance to LLR general practices, including access to adult, paediatric and infant screening and action tools.
Verbatim wording from the response “In addition, the CCG’s Head of Infection Control has arranged for an email to be circulated to all GPs within Leicester, Leicestershire and Rutland (LLR) entitled ‘Managing Sepsis’ as follows:” Source location ROBEY-Responses
Open published response
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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 Highlight the importance of diagnosing sepsis and using the sepsis screening tool through the local medical committee.
Verbatim wording from the response “NHS England has, through the local medical committee, highlighted the importance of diagnosing sepsis and the use of the sepsis screening tool (attached).” Source location Response from NHS England
Open published response
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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 Develop an approved system for reviewing and implementing patient safety alerts, with subsequent assurance reporting to the Clinical Governance Committee.
Verbatim wording from the response “I would again refer you to the enclosed action plan developed by the Loughborough Urgent Care Centre. As you will note, an approved system to review and implement patient safety alerts at the Loughborough Urgent Care Centre will be developed by January 2016, with regular assurance reports subsequently provided to the Clinical Governance Committee at CNCS on the implementation of all relevant Patient Safety Alerts.” Source location ROBEY-Responses
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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 Hold a meeting with University Hospitals of Leicester to share sepsis quality-improvement experience and materials and obtain implementation support.
Verbatim wording from the response “I can further confirm that a WLCCG Board GP, Dr Chris Barlow, has a meeting arranged with Dr John Parker, a Critical Care Consultant at the University Hospitals of Leicester (UHL), on 15 December 2015; UHL have successfully implemented a number of quality improvements projects for sepsis in UHL, they have offered to meet with the CCG with the aim of sharing their experience/materials and to provide support in ensuring that staff have a developed understanding of the management of sepsis.” Source location ROBEY-Responses
Open published response
Concerns raised 1
Failure of newly qualified clinicians to identify sepsis deaths in children View source
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Ella Rose Block · 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
Ella Rose Block was admitted to Derriford Hospital on 1 March 2013, unwell and feverish, deteriorated overnight, and died on 2 March 2013. The concerns identified were that an opportunity may have been missed to provide suitable treatment and that newly qualified clinicians may not readily identify deaths of children resulting from sepsis.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of newly qualified clinicians to identify sepsis deaths in children
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
An opportunity may have been missed to provide suitable treatment. Deaths of children as a result of Sepsis are fortunately rare but as a result new qualified clinicians are not readily identifying such deaths
” Source location Ella Rose Block · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.