Recurring concern

Inconsistent clinical guidance for antibiotic decisions in suspected sepsis

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First reported 18 Jan 2022•Latest report 12 Aug 2023

Definition

What this concern includes

Includes deficiencies in clinical guidance, protocols or decision criteria specifically governing antibiotic decisions for suspected sepsis, including unclear thresholds, conflicting guidance systems, omitted decision-maker involvement and inadequate clarification of how competing guidance should be applied.

Not included

  • Excludes antibiotic guidance for conditions without a suspected-sepsis context, including isolated meningitis, gastroenteritis, prolonged rupture of membranes or group B streptococcal colonisation unless the assertion also explicitly concerns suspected sepsis.
  • Excludes generic sepsis recognition, staffing, pre-alerting or treatment-delivery failures where antibiotic decision guidance is not the unsafe condition.
  • Excludes failures to follow clear and consistent suspected-sepsis antibiotic guidance when the guidance itself is adequate.
  • Excludes the underlying risk of haemolytic uraemic syndrome or other complications unless the assertion specifically concerns unclear guidance for antibiotic decisions in suspected sepsis.
Reports
2

Distinct published reports

Individual concerns
3

A report can raise multiple concerns

Date range
2022–2023

First to latest report issue date

Stated actions
3

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.

British Association of Perinatal Medicine1
National Institute for Health and Care Excellence1
NHS England1
Royal College of Paediatrics and Child Health1
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 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

    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

    Coco Bradford · 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

    Coco Bradford, a 6-year-old girl with autism, developed diarrhoea and vomiting, was diagnosed with haemolytic uraemic syndrome, deteriorated despite treatment and died in Bristol on 31 July 2017. The substantive concerns relate to the size and review of intravenous fluid boluses, when to escalate intensive care, and how clinicians should weigh antibiotic treatment when bacterial gastroenteritis and possible sepsis coexist because antibiotics may worsen haemolytic uraemic syndrome.

    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 guidance for balancing antibiotic and HUS risks in suspected sepsis

    Wider context from the report

    “2) A second issue that came out of Coco’s inquest was the clinical conundrum of how to treat a child with bacterial (e coli 0157) gastroenteritis who is suspected of having a concomitant sepsis. The dilemma is that the administration of antibiotics may precipitate or worsen HUS and, if the child is subsequently found not to have sepsis, may inadvertently cause harm. It may be that you will feel that guidance on how to weigh the balance of risk and who to involve in the decision-making process would be of assistance to clinicians generally. ”

    Source location

    Coco Bradford · 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 guidance on who to involve in antibiotic decisions for suspected sepsis with possible HUS

    Wider context from the report

    “2) A second issue that came out of Coco’s inquest was the clinical conundrum of how to treat a child with bacterial (e coli 0157) gastroenteritis who is suspected of having a concomitant sepsis. The dilemma is that the administration of antibiotics may precipitate or worsen HUS and, if the child is subsequently found not to have sepsis, may inadvertently cause harm. It may be that you will feel that guidance on how to weigh the balance of risk and who to involve in the decision-making process would be of assistance to clinicians generally. ”

    Source location

    Coco Bradford · 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

    Balancing antibiotic risks in suspected sepsis is considered clinical judgement and cannot be addressed by a guideline.

    Verbatim wording from the response

    “Finally, you also note the difficulty of treating a child with bacterial gastroenteritis who is suspected to have concomitant sepsis and ask if guidance on ‘how to weigh the balance of risk and who to involve in the decision-making process’ would be useful. Reflecting on the specific issue raised in your report, that ‘the administration of antibiotics may precipitate or worsen [haemolytic uraemic syndrome]’ and, if the child is subsequently found not to have sepsis, may inadvertently cause harm’, we consider this to be a matter of clinical judgement and not something that could be addressed by a guideline. Haemolytic uraemic syndrome is”

    Source location

    2022-0012-Response-from-NICE_Published
    Page 1 · response
    Published 20 January 2022

    Open published response
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Data last updated 7 September 2026