Recurring concern

Failure to reliably recognise and respond to epiglottitis in adults

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First reported 2 Nov 2015•Latest report 15 Aug 2023

Definition

What this concern includes

Includes failures in the dedicated clinical recognition and response process for epiglottitis in adults, including clinician knowledge, recognition of adult presentations and symptoms, diagnostic consideration, urgent escalation, airway assessment and prompt treatment.

Not included

Excludes generic respiratory, sore-throat, airway-emergency or clinical-recognition deficiencies where adult epiglottitis is not materially identified.
Excludes paediatric epiglottitis unless the assertion explicitly supports the same adult-epiglottitis recognition and response concern.
Excludes failures occurring after adult epiglottitis has been reliably recognised and escalated, including unrelated downstream treatment or recovery deficiencies.
Excludes generic training, staffing, communication or documentation deficiencies unless they directly impair recognition or response to adult epiglottitis.

Reports: 2
Individual concerns: 2
Date range: 2015–2023
Stated actions: 2

Reports 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

Bevan Brittan LLP1

East of England Ambulance Service NHS Trust1

General Medical Council1

Irwin Mitchell LLP1

Royal College of Emergency Medicine1

Royal College of General Practitioners1

Southend University Hospital1

Urgent Health UK Limited1

Weightmans LLP1

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.

15 Aug2023
Milton Keynes
Concerns raised1
1. Failure to recognise epiglottitis in adults
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Develop new ambulance guidance that covers adult epiglottitis, key assessment and management points, and rapid conveyance for lifesaving treatment.
  Stated by Association of Ambulance Chief ExecutivesStated in progress
2. Action
  Arrange distribution of the Regulation 28 Report to Medical and Nurse Directors across UHUK’s 30 member organisations.
  Stated by Urgent Health UK LimitedStated completed
Respondent positions 2
1. Position
  Training and education of ambulance staff are outside the respondent’s responsibility.
  Stated by Association of Ambulance Chief ExecutivesOutside remit
1. Position
  Individual ambulance services are responsible for considering whether adult epiglottitis education or awareness-raising is required.
  Stated by Association of Ambulance Chief ExecutivesRedirects responsibility
AI-generated summary

Leonard Jomo Isaac KING · 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

Leonard Jomo Isaac King died at Milton Keynes University Hospital on 4 May 2022 following a hypoxic cardiac arrest caused by airway obstruction from epiglottitis. The report identified concerns that adult epiglottitis may be mistaken for a sore throat or tonsillitis, and that there were missed opportunities to recognise and escalate his condition and transfer him to an emergency department.

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 recognise epiglottitis in adults
Wider context from the report
“Subsequent to mass immunisation the demographic has changed and more adults are developing epiglottitis. It is not common in this group but because of the expectation among clinicians that it is a still a disease of children, there is a tendency, except in those routinely dealing with acute emergencies of the airways, to regard typical symptoms as those of a sore throat or tonsillitis and not as the harbinger of sudden catastrophic obstructive epiglottitis. The disease classically develops rapidly in children but in adults may take several days which may be falsely reassuring. Typical symptoms may include a sore throat which becomes more severe with time, difficulty swallowing secretions, pain on swallowing and an alteration in voice. Prompt recognition and treatment is lifesaving. ”
Source location
Leonard Jomo Isaac KING · 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
Develop new ambulance guidance that covers adult epiglottitis, key assessment and management points, and rapid conveyance for lifesaving treatment.

Verbatim wording from the response
“With regard to the UK ambulance service clinical practice guidelines (the “JRCALC guidelines”). The guidelines are in regular use by ambulance clinicians across the UK and guide decisions on the assessment and management of a wide range of clinical presentations. We currently have guidance for children with suspected epiglottitis but not for adults. We had already started to scope and develop new guidance for ambulance clinicians on rarer and specific conditions that need pre-hospital clinical assessment and management that differs from standard practice. We appreciate the importance of the prompt recognition or suspicion of suspected epiglottitis in adults and that typical symptoms may include a sore throat which becomes more severe with time, difficulty swallowing secretions, pain on swallowing and an alteration in voice.”

Source location
Response from Association of Ambulance Chief Executives
Page 1 · response
Published 6 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
Arrange distribution of the Regulation 28 Report to Medical and Nurse Directors across UHUK’s 30 member organisations.

Verbatim wording from the response
“Thank you for the Regulation 28 Report. On behalf of Conor Burke CEO UHUK, I have arranged for all Medical Directors and Nurse Directors of our 30 members to receive a copy of the Report and asked them to distribute it to their front line clinicians using their standard communication mechanisms (attached emails). These clinicians provide care to 65% of the UK population. In addition the report will be reviewed and discussed at the Medical Directors and Nurse Directors Teams Meeting to be held on 18th September 2023, 1-2pm.”

Source location
Response from Urgent Health UK
Page 1 · response
Published 6 September 2023
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
Training and education of ambulance staff are outside the respondent’s responsibility.

Verbatim wording from the response
“AACE are not responsible for the training or education of ambulance staff, however we plan to share and discuss this preventing future death report with ambulance service medical directors at our next meeting. We will suggest that individual ambulance services consider if any education or raising awareness of epiglottitis in adults is required. We will also share the report with education leads of ambulance trusts, via the national education network for ambulance trusts.”

Source location
Response from Association of Ambulance Chief Executives
Page 1 · response
Published 6 September 2023
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
Individual ambulance services are responsible for considering whether adult epiglottitis education or awareness-raising is required.

Verbatim wording from the response
“AACE are not responsible for the training or education of ambulance staff, however we plan to share and discuss this preventing future death report with ambulance service medical directors at our next meeting. We will suggest that individual ambulance services consider if any education or raising awareness of epiglottitis in adults is required. We will also share the report with education leads of ambulance trusts, via the national education network for ambulance trusts.”

Source location
Response from Association of Ambulance Chief Executives
Page 1 · response
Published 6 September 2023
Open published response
2 Nov2015
Essex
Concerns raised1
1. Lack of up-to-date knowledge among general practitioners about epiglottitis in adults
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Steven David Jackson · 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

Steven David Jackson attended Southend Hospital on 5 March 2014, was later taken there by ambulance after collapsing, and died at 14:26. The inquest recorded acute epiglottitis as the cause of death and identified very serious failings in the care provided by ambulance staff. Concerns also included an out-of-hours general practitioner’s apparently outdated knowledge of epiglottitis in adults.

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 up-to-date knowledge among general practitioners about epiglottitis in adults
Wider context from the report
“1. The general practitioner, employed by the out of hours service IC24, seemed to have out of date knowledge of the incidence of epiglottitis generally. He seemed to be under the impression that it was still very much a condition found among children and would not be expected in an adult such as Mr Jackson. ”
Source location
Steven David Jackson · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to recognise epiglottitis in adults

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Lack of up-to-date knowledge among general practitioners about epiglottitis in adults

Actions described in response 2

Respondent positions 2