Recurring concern

Inconsistent paediatric sepsis recognition and response guidance

First to latest report 2 Feb 2016 — 28 Feb 2020

Reports that mention this concern: 3
Times this concern has been raised: 5
Stated actions linked to this concern: 5

What this concern includes

Includes only assertions that directly instantiate the manually reviewed condition ‘Inconsistent paediatric sepsis recognition and response guidance’ and satisfy this evidence boundary: Two distinct reports directly support unclear paediatric sepsis terminology and conflicting heart-rate thresholds for urgent sepsis treatment. The separate assertion about applying fever-assessment guidance to infants does not directly establish sepsis and must be excluded.

What is not included

Excludes adult sepsis guidance and sepsis concerns with no paediatric qualifier.
Excludes failures in antibiotic selection or treatment delivery where paediatric sepsis recognition-and-response guidance is not the deficient control.
Excludes failures to perform investigations or provide equipment when the guidance and recognition process itself is reliable.
Excludes generic clinical training or communication deficiencies unless they directly impair paediatric sepsis recognition-and-response guidance.
Excludes manifestations outside the manually reviewed boundary: Two distinct reports directly support unclear paediatric sepsis terminology and conflicting heart-rate thresholds for urgent sepsis treatment. The separate assertion about applying fever-assessment guidance to infants does not directly establish sepsis and must be excluded.

Trends

Reports over time

Reports mentioning this concern, over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

Association of Ambulance Chief Executives1

Cardiff & Vale University LHB1

Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust1

East of England Ambulance Service NHS Trust1

National Institute for Health and Care Excellence1

Reports and published responses 3 reports

See individual reports that have raised this concern, and the actions taken in response

28 Feb2020
South Wales Central
Concerns raised1
1. Failure to use and record clear, continuing sepsis terminology in suspected sepsis patients
This report raised 5 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.
AI-generated summary

Lewys Ryan Aidan CRAWFORD · 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

Lewys Ryan Aidan CRAWFORD was admitted to A&E on 21 March 2019 while likely in the early stages of meningococcal disease and died on 22 March 2019 after transfer to the Paediatric Critical Care Unit. The report identified missed opportunities to recognise sepsis, failure to administer antibiotics before 11:30pm, and concerns about staff training, use of sepsis guidance, terminology, and alternative antibiotic administration methods.

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 use and record clear, continuing sepsis terminology in suspected sepsis patients
Wider context from the report
“(3) Guidance and instruction to both clinicians and nurses as to the appropriate use (and recording) of terminology should be considered in suspected sepsis patients. There was a degree of confusion in both the A & E & Paediatric Departments caused by the interchangeable use of sepsis and bacterial infection as to what treatment should be initiated/progressed depending on which description was used. If sepsis is suspected, that clear and continuing reference ought to be maintained, if, and until it is superseded by an alternative diagnosis. ”
Source location
Lewys Ryan Aidan CRAWFORD · Prevention of Future Deaths report
Page 2 · concerns
Open source report
17 Jun2019
Suffolk
Concerns raised1
1. Lack of clear and consistent guidance on heart-rate criteria triggering urgent sepsis treatment in sick six-year-old children
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses

Association of Ambulance Chief Executives
East of England Ambulance Service NHS Trust
National Institute for Health and Care Excellence
Stated actions 3
1. East of England Ambulance Service NHS Trust
  Provide sepsis training and embed UK Sepsis Trust guidance in the electronic Clinical Manual for staff.
2. Association of Ambulance Chief Executives
  Ask JRCALC to consider whether evidence supports changing ambulance guidance on paediatric pulse-rate thresholds.
3. National Institute for Health and Care Excellence
  Review and amend the CKS Meningitis topic to align with NICE sepsis guidance.
Respondent positions 4
1. East of England Ambulance Service NHS Trust
  NICE guidance provides clarity on recognising high-risk sepsis, including severe tachycardia thresholds for children aged six to seven years.
  Disputes the concern
1. East of England Ambulance Service NHS Trust
  Existing endorsement of UK Sepsis Trust and NICE-aligned guidance, training, and the Clinical Manual adequately address paediatric sepsis recognition.
  Existing arrangements considered sufficient
2. Association of Ambulance Chief Executives
  A pulse rate of 119 rather than 120 beats per minute would not independently influence assessment of a six-year-old child.
  Disputes the concern
3. National Institute for Health and Care Excellence
  NICE disputes that its sepsis guidance lacks clarity, citing defined heart-rate thresholds for children aged 6–7 years.
  Disputes the concern
AI-generated summary

Oliver Hall · 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

Oliver Hall, a six-year-old boy, became acutely unwell on 23 October 2017 and died in the early hours of 24 October 2017 after developing meningococcal septicaemia. The report identified concerns about NHS 111 disposition information not being transferred to ambulance and treating clinicians, delays in ambulance availability information, and conflicting guidance about the significance of his heart rate.

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
Lack of clear and consistent guidance on heart-rate criteria triggering urgent sepsis treatment in sick six-year-old children
Wider context from the report
“3. It was apparent from the evidence given by both the ambulance crew and treating doctors that there was some lack of clarity over the current National Institute for Health Care Excellence guidance on the treatment of sepsis and the guidance provided by the Joint Royal Colleges Ambulance Liaison Committee. This lack of clarity centred around the heart rate which should trigger a medical treatment response in a sick six-year-old child. Evidence heard stated that a heart rate of 120 beats per minute was given in some guidance as being at the top end of the normal range for a six-year-old child. The health professionals involved in Oliver’s case said they had relied on this guidance. However, in other guidance a heart rate of 120 beats per minute in a six-year-old child is considered to be a high-risk criteria in cases of suspected sepsis requiring an urgent response. The health professionals involved in Oliver’s case said they were either unaware of this guidance, or they were aware of it but placed their reliance on the ‘normal range’ guidance above. Therefore, it is apparent that the significance of Oliver’s heart rate of 120 beats per minute was not identified as being a symptom of his meningococcal septicaemia by the health professionals responsible for his treatment, likely to be due to the nature of the conflicting guidance as detailed above. ”
Source location
Oliver Hall · Prevention of Future Deaths report
Page 3 · 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
Provide sepsis training and embed UK Sepsis Trust guidance in the electronic Clinical Manual for staff.

Verbatim wording from the response
“EEAST has, for a number of years followed and endorsed the work of the UK Sepsis Trust that mirrors the NICE guidance. This endorsement has included provision of core and professional update training to our staff and used within our ‘Clinical Manual’ – an electronic resource available to staff that is designed to augment the guidance offered by JRCALC.”

Source location
2019-0198-Response-by-East-of-England-Ambulance-Service-NHS-Trust
Page 2 · response
Published 23 August 2019
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
Ask JRCALC to consider whether evidence supports changing ambulance guidance on paediatric pulse-rate thresholds.

Verbatim wording from the response
“Since being made aware of the disparity in pulse ranges quoted by NICE, JRCALC and other guidelines we have asked JRCALC to consider whether there is sufficient evidence to change their current guidance for ambulance staff.”

Source location
2019-0198-response-by-Association-of-Ambulance-Chief-Executives
Page 3 · response
Published 23 August 2019
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
Review and amend the CKS Meningitis topic to align with NICE sepsis guidance.

Verbatim wording from the response
“In addition to NICE guidance, our website provides access to Clinical Knowledge Summaries (CKS) which set out the current evidence base and best practice on more than 360 common and significant primary care presentations. These summaries are commissioned by NICE, but they are not formal NICE guidelines. They are authored by an external contractor using a development process that has been accredited by NICE.”

Source location
2019-0198-Response-by-NICE
Page 2 · response
Published 23 August 2019
Open published response
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
NICE guidance provides clarity on recognising high-risk sepsis, including severe tachycardia thresholds for children aged six to seven years.

Verbatim wording from the response
“A lack of clarity was apparent over the current national institute for health care and excellence on the treatment of sepsis and the guidance provided by the joint royal college’s ambulance liaison committee, specifically in matters of the pulse rate of 120 in a six year.”

Source location
2019-0198-Response-by-East-of-England-Ambulance-Service-NHS-Trust
Page 2 · response
Published 23 August 2019
Open published response
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
Existing endorsement of UK Sepsis Trust and NICE-aligned guidance, training, and the Clinical Manual adequately address paediatric sepsis recognition.

Verbatim wording from the response
“EEAST has, for a number of years followed and endorsed the work of the UK Sepsis Trust that mirrors the NICE guidance. This endorsement has included provision of core and professional update training to our staff and used within our ‘Clinical Manual’ – an electronic resource available to staff that is designed to augment the guidance offered by JRCALC.”

Source location
2019-0198-Response-by-East-of-England-Ambulance-Service-NHS-Trust
Page 2 · response
Published 23 August 2019
Open published response
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
A pulse rate of 119 rather than 120 beats per minute would not independently influence assessment of a six-year-old child.

Verbatim wording from the response
“Having consulted with the National Ambulance Service Medical Directors group (NASMeD), they are clear that the difference between 119 or 120bpm as a pulse rate in a 6-year-old child would not be influential on its own. The attending ambulance staff have been taught that the assessment of the child with regard to severity of illness and possible causes would be influenced by a range of observations, signs, symptoms and history. It is fundamental to ambulance service clinical practice to ascertain a comprehensive history of events and conduct a thorough patient assessment. It is only by doing this that information received can be verified and form part of subsequent decision making.”

Source location
2019-0198-response-by-Association-of-Ambulance-Chief-Executives
Page 3 · response
Published 23 August 2019
Open published response
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
NICE disputes that its sepsis guidance lacks clarity, citing defined heart-rate thresholds for children aged 6–7 years.

Verbatim wording from the response
“We have considered the circumstances surrounding Oliver’s death and the concerns raised in your report. In particular, the concerns raised regarding the NICE guidance on treatment of sepsis and a perceived lack of clarity over the heart rate which should trigger a medical treatment response in an unwell 6 year old child.”

Source location
2019-0198-Response-by-NICE
Page 1 · response
Published 23 August 2019
Open published response
2 Feb2016
South Yorkshire (Eastern)
Concerns raised3
1. Lack of clarity about paediatric sepsis signs and responses
2. Lack of paediatric sepsis treatment protocol and guidance
3. Unclear and interchangeable use of paediatric sepsis terminology
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Stated actions 2
1. Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
  Implement and disseminate an agreed paediatric sepsis toolkit across clinical areas.
2. Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
  Provide multidisciplinary training on paediatric sepsis and unexpected deterioration, including training for medical staff during each house induction.
AI-generated summary

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.

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
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
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
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
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
Unclear and interchangeable use of paediatric sepsis terminology
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
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
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
Page 2 · response
Published 2 February 2016
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
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
Page 3 · response
Published 2 February 2016
Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

Data last updated 7 September 2026

What this concern includes

Trends

Reports mentioning this concern, over time

Concerns raised1

Failure to use and record clear, continuing sepsis terminology in suspected sepsis patients

Concerns raised1

Lack of clear and consistent guidance on heart-rate criteria triggering urgent sepsis treatment in sick six-year-old children

Linked responses

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4

Concerns raised3

Lack of clarity about paediatric sepsis signs and responses

Lack of paediatric sepsis treatment protocol and guidance

Unclear and interchangeable use of paediatric sepsis terminology

Linked response

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Stated actions 3

Respondent positions 4

Stated actions 2