Recurring concern

Failure to recognise and respond promptly to suspected meningitis

First to latest report 14 Jan 2014 — 3 Jul 2019

Reports that mention this concern
5
Times this concern has been raised
6
Stated actions linked to this concern
4

What this concern includes

Includes failures in the recognition, assessment, escalation, admission, treatment response, discharge safety-netting or communication processes specifically tied to suspected or possible meningitis.

What is not included
  • Generic failures to admit, assess or communicate that are not specifically tied to suspected meningitis.
  • Failures concerning other infections, diagnoses or clinical hazards.
  • Generic staffing, training, documentation or capacity deficiencies unless the source explicitly ties them to the recognition or management of suspected meningitis.

Reports and published responses 5 reports

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

  1. Cornwall and Isles of Scilly

    AI-generated summary

    Jennifer Withey · 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

    Jennifer Withey died from sepsis following infection associated with a spinal fusion operation, after contacting the 111 service three times. During one call, recorded symptoms included inability to weight bear, no urine for 30 hours, and a dead-feeling left arm and leg, but the call was not immediately referred to a clinician. The report raised concerns about the lack of an automatic sepsis alert and separate timeframes operated by the 111 and out-of-hours GP services, which could introduce avoidable delay.

    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 the free text box to generate automatic red flags from identified symptoms

    Wider context from the report

    “A) The free text box could be set up so that identified symptoms, where appropriate, could generate an automatic red flag. By way of illustration, a non-blanching rash could automatically justify immediate hospital admission by ambulance in a case of suspected meningitis. Similarly, in this case, where a number of sepsis indicators were present, a red flag could have been raised requiring the call adviser specifically to consider a sepsis pathway. This would act as a second level of security, the first step being to allocate a patient to a correct pathway in the first instance. ”

    Source location

    Jennifer Withey · 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

    NHS Digital is responsible for delivering NHS Pathways and its Directory of Service clinical decision tool.

    Verbatim wording from the response

    “NHS Digital is responsible for the delivery of NHS Pathways and the ‘Directory of Service’ which is a clinical decision tool. Together this system is used throughout England and underpins how the public access all urgent and emergency care”

    Source location

    2019-0225-Response-by-NHS-England
    Page 1 · response
    Published 13 September 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

    NHS Digital’s separate response is considered to cover and answer all specific NHS Pathways recommendations.

    Verbatim wording from the response

    “As mentioned earlier, I note that NHS Digital has already responded separately to you on the specific NHS Pathways recommendations in your referral and I am content that its response suitably covers, and answers, all of the issues you raised.”

    Source location

    2019-0225-Response-by-NHS-England
    Page 2 · response
    Published 13 September 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

    Free-text analysis cannot safely be introduced because sufficient expertise and evidence do not currently exist; developing technology remains under review.

    Verbatim wording from the response

    “• It may be in time that technology, natural language processing and artificial intelligence develop such that free text analysis of this nature can successfully be deployed but NHS Pathways do not consider that sufficient expertise or evidence exists currently to safely introduce such a feature. Use of developing technology is something that remains under constant review in NHS Pathways.”

    Source location

    2019-0225-Response-by-NHS-Digital
    Page 5 · response
    Published 13 September 2019

    Open published response

  2. Avon

    AI-generated summary

    Yazin ELHAJE · 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

    Yazin Elhaje became ill with suspected meningitis, was initially discharged with a diagnosis of sinusitis, deteriorated, and died from bacterial meningitis on 8 October 2017 despite treatment. The principal concern was that discharge safety-netting advice to his parents addressed headaches rather than the differential diagnosis of meningitis.

    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 safety-netting advice addressing meningitis when it is part of the differential diagnosis

    Wider context from the report

    “I heard during the inquest that the safety-netting advice on discharge given to Yazin’s parents was in relation to his headaches and not in relation to the differential diagnosis of meningitis. I would ask that consideration is given to the safety-netting advice provided to parents in cases where meningitis has been considered as part of the differential diagnosis as in this case. ”

    Source location

    Yazin ELHAJE · 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 a safety-netting process and leaflet for families of children presenting with sinusitis, including information about rare complications such as meningitis.

    Verbatim wording from the response

    “Following this incident the Emergency Department governance lead has led the development of an information leaflet to be given to families whose children present with sinusitis that includes information about rare potential complications such as meningitis.”

    Source location

    Response from University Hospitals Bristol NHS Trust
    Page 1 · response
    Published 6 November 2024

    Open published response

  3. Manchester South

    AI-generated summary

    Mikey James Hornby · 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

    Mikey James Hornby was born on 31 March 2014 and died after being found lifeless at home on the morning after he attended an out-of-hours service with strange breathing. The report records neonatal E. coli sepsis and meningitis, with the conclusion of natural causes contributed to by neglect. Concerns included failures to refer him to hospital when he had an infected umbilical cord or possible serious illness, and the lack of access to immediate blood testing and antibiotics.

    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 immediately admit children when meningitis is a realistic possibility

    Wider context from the report

    “1. On the first attendance at the OOH service, the attending staff having seen the infected umbilical cord, did not immediately send Mikey to the Hospital (as would have been the correct procedure according to the Consultant Lead Paediatrician who gave evidence to me.) 2. On the second attendance the doctor failed to appreciate the seriousness of the situation and at 10.45 at night sent the child home with a prescription for analgesia (which could not be filled until the following day in any event). The Consultant Paediatrician gave evidence to me “that there was a very high probability that he would have survived” had he been sent to the hospital at this time as he could and would have been administered an intra-venous anti-biotic. 3. If there is any realistic possibility of the condition being meningitis, the child should have been immediately admitted to the hospital. 4. The GP covering the surgery that night indicated that they do not have the facility to take a simple blood test. If this is the case, then they should utilise the adjacent facilities at the Emergency Department of the hospital. ”

    Source location

    Mikey James Hornby · Prevention of Future Deaths report
    Page 1 · 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 immediately refer children with infected umbilical cords to hospital at first OOH attendance

    Wider context from the report

    “1. On the first attendance at the OOH service, the attending staff having seen the infected umbilical cord, did not immediately send Mikey to the Hospital (as would have been the correct procedure according to the Consultant Lead Paediatrician who gave evidence to me.) 2. On the second attendance the doctor failed to appreciate the seriousness of the situation and at 10.45 at night sent the child home with a prescription for analgesia (which could not be filled until the following day in any event). The Consultant Paediatrician gave evidence to me “that there was a very high probability that he would have survived” had he been sent to the hospital at this time as he could and would have been administered an intra-venous anti-biotic. 3. If there is any realistic possibility of the condition being meningitis, the child should have been immediately admitted to the hospital. 4. The GP covering the surgery that night indicated that they do not have the facility to take a simple blood test. If this is the case, then they should utilise the adjacent facilities at the Emergency Department of the hospital. ”

    Source location

    Mikey James Hornby · Prevention of Future Deaths report
    Page 1 · 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 NICE feverish-illness guidance in the out-of-hours service using PEWS and assessment templates.

    Verbatim wording from the response

    “In 2013, the Trust implemented national NICE guidance dated May 2013 entitled “Feverish illness in children: Assessment and initial management in children younger than 5 years” which is based on validated algorithms. A copy of a link to the NICE guidance is enclosed, for your ease of reference: http://www.nice.org.uk/cg160/chapter/recommendations.”

    Source location

    2014-0536-Response-by-Bridgewater-Community-Healthcare-NHS-Trust
    Page 2 · response
    Published 16 December 2014

    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

    Conduct quarterly clinical audits of practitioners’ records and provide supervision and competency action plans where practice falls short.

    Verbatim wording from the response

    “Ongoing checks on the quality of the services we provide are made via quarterly clinical audit reviews, where a sample of clinical and medical records from each practitioner are reviewed by the clinical director enabling best practice to be recognised and shared with colleagues. Where best practice is not followed a period of supervision and formal support with competency improvement action plans is implemented.”

    Source location

    2014-0536-Response-by-Bridgewater-Community-Healthcare-NHS-Trust
    Page 3 · response
    Published 16 December 2014

    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 training on managing severely ill children for out-of-hours GPs alongside mandatory and statutory training.

    Verbatim wording from the response

    “Annual appraisals take place with all staff. Learning from incidents in service allows GPs to review their training needs so that alongside maintaining their annual Mandatory and Statutory Training, particular development needs can be met. For GPs in the Out of Hours Service, their Bridgewater-specific training will often run alongside the continuing professional development they undertake as part of their practice. In ████████ case, he has undertaken training on management of the severely ill child to support his general practice role.”

    Source location

    2014-0536-Response-by-Bridgewater-Community-Healthcare-NHS-Trust
    Page 3 · response
    Published 16 December 2014

    Open published response

  4. Cardiff & the Vale of Glamorgan

    AI-generated summary

    Thomas George Smith · 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

    Thomas George Smith, aged 13, developed symptoms including headache, neck pain and vomiting before being admitted to hospital, where he later became unresponsive and died after suspected meningitis and raised intracranial pressure. The report identified concerns about delays in recognising and treating meningitis and raised intracranial pressure, communication and handover, responding to nursing concerns, monitoring physiological trends, and the transfer of the patient to hospital.

    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 retain meningitis as a differential diagnosis

    Wider context from the report

    “(4) It appeared at the inquest if the clinicians had adopted an “exclusionary focus” to rule out meningitis rather than an “inclusionary focus” so as to be able to adopt a diagnosis of meningitis as a differential diagnosis. The Coroner considers that the inclusionary approach is appropriate where a patient presents with some of the signs of meningitis. It should be standard practice at PCH for raised Intracranial pressure to be treated without delay even if a diagnosis is awaited on the underlying condition. ”

    Source location

    Thomas George Smith · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  5. South Lincolnshire

    AI-generated summary

    Craig Adam White · 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

    Craig Adam White was a 21-year-old student who developed disseminated tuberculosis, including tuberculosis leptomeningitis, while receiving immunosuppressive treatment for Crohn’s disease. He had recurrent chest infections and later deteriorated with neurological illness before tuberculosis was confirmed. The principal concerns were tuberculosis screening before Infliximab treatment, healthcare professionals’ awareness of the associated risk, continuing patient education, and prompt treatment when tuberculous meningitis is suspected.

    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

    Delays in initiating treatment when tuberculous meningitis is suspected

    Wider context from the report

    “4 The need for prompt treatment to be initiated when tuberculous meningitis is suspected ”

    Source location

    Craig Adam White · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

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

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Data last updated 7 September 2026