Recurring concern

Failure to reliably recognise respiratory distress in children

First to latest report 5 Mar 2015 — 21 Feb 2020

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

What this concern includes

Includes failures in paediatric processes for recognising, assessing or escalating respiratory distress, including atypical presentations in children with myopathies, respiratory-rate assessment, oxygen-saturation monitoring and recognition of respiratory red flags such as shortness of breath, chest pain or cyanosis.

What is not included
  • Excludes adult respiratory assessment and treatment unless the assertion explicitly supports the same paediatric respiratory-distress recognition process.
  • Excludes management of confirmed respiratory distress after it has been reliably recognised and escalated.
  • Excludes generic clinical deterioration, staffing, training or communication deficiencies unless they directly impair recognition of respiratory distress in children.
  • Excludes unrelated paediatric conditions or monitoring systems where respiratory distress is not the material safety concern.

Reports and published responses 3 reports

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

  1. Mid Kent and Medway

    AI-generated summary

    LUKE OWEN 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

    Luke Owen Jackson, who had Becker’s Muscular Dystrophy and a chest infection, was admitted to hospital on 4 December 2019 and suffered a cardiac arrest on 6 December before being transferred to the Evelina Children’s Hospital. He later died on palliative care from hypoxic ischaemic encephalopathy following prolonged cardiac arrest. The principal concerns included recognition and treatment of total-body potassium depletion in a child with myopathy, and the limitations of monitoring oxygen saturation when assessing deterioration.

    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

    Atypical presentation of respiratory distress in children with myopathies weakened by low potassium

    Wider context from the report

    “The Trust has taken action to address the conclusions of its Root Cause Analysis and has learned and disseminated lessons, improving its processes. This Report is made to assist learning in the public interest as evidence was heard from a consultant from a specialist children’s hospital that total body potassium depletion is not always recognised in children with myopathies who become unwell. They may present with diarrhoea and vomiting due to shunting of the blood away from the gut to protect vital organs such as the brain and heart. (1) Luke had complex needs and was awaiting results of genetic testing confirmed as Becker’s Muscular Dystrophy. He had not been eating and drinking, had loose stools and vomiting that had progressed over a five-day period in a background of a chest infection. His parents had sought and followed medical advice from the hospital by telephone. Luke continued to deteriorate, and he was admitted. The Trust took some steps on admission to address his low potassium. (2) Evidence was heard from a Consultant from the Evelina Children’s Hospital that they get almost 2000 referrals a year and many have diarrhoea and vomiting as a first symptom. Issues relating to metabolic derangement in a child with myopathies is not always recognised as total body potassium depletion and that treatment may need to be undertaken in intensive care due to the increased amounts of potassium required to correct the derangement and manage clinical risks: (i) Children with Myopathies - have low muscle mass that compromises their ability to correct their own potassium levels when unwell. (ii) Luke had a chest infection, however his low potassium made him weaker and as it progressed, he was shunting blood away from his gut to compensate (this assists to protect the vital organs such as the heart and brain) which resulted in loose stools and vomiting; this was not a consequence of gastroenteritis. One of the early symptoms of this shunting process is a high heart rate. (iii) A bolus of potassium and fluid resuscitation to treat gastroenteritis was not sufficient to treat total body potassium depletion which requires a central line with significant potassium replacement in intensive care to manage clinical risk. (iv) Development of a chest infection requires a child to breath harder and this becomes more difficult in a child with myopathies that is already weakened due to low potassium and will not present with the usual symptoms of respiratory distress. (v) As Luke was treated with oxygen therapy, the monitor alarm set for oxygen saturations did not sound as his oxygen did not deplete and he went into cardiac arrest ”

    Source location

    LUKE OWEN JACKSON · 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

    Update paediatric guidelines to strengthen recognition, senior assessment, monitoring and management of children with myopathies and hypokalaemia, including STRS contact indications.

    Verbatim wording from the response

    “The Trust has updated their Paediatric Guidelines (GUDPCM016) in response to patients with myopathies to reflect that:”

    Source location

    2021-0052-Response-from-Medway-Maritime-Hospital-Redacted
    Page 2 · response
    Published 1 March 2021

    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 considers existing general guidance on assessment, monitoring, and altering care as indicated appropriate.

    Verbatim wording from the response

    “It is the view of NICE that the current general guidance about assessment, monitoring, and altering care as indicated is appropriate.”

    Source location

    2021-0052-Response-from-Dept-of-Health-and-Social-Care-Redacted
    Page 2 · response
    Published 1 March 2021

    Open published response

  2. Cornwall and Isles of Scilly

    AI-generated summary

    Esmee Shayla Polmear · 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

    Esmee Polmear fell ill during a school trip on 1 July 2015, later collapsed and went into cardiac arrest, and was pronounced dead in hospital despite resuscitation attempts. She had pulmonary veno-occlusive disease that was not diagnosed or recognised before her death; concerns included the use of respiratory-rate benchmarks and oxygen monitoring, and recognition and action on red-flag symptoms.

    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 and act on paediatric respiratory red flag markers

    Wider context from the report

    “At the inquest the Paediatric Expert, ████████ gave the opinion that • The routine use of respiratory rate bench-markers in paediatric respiratory medicine • The use of routine oxygen blood monitoring in paediatric medicine • The recognition and action on red flag markers (which in this case were shortness of breath, chest pain and blue lips) Would have assisted and improved the chances of diagnosis and treatment of Esmee and other children, with a view to preventing future deaths or providing appropriate treatment and palliative care in life limiting cases. ”

    Source location

    Esmee Shayla Polmear · 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 routinely use oxygen blood monitoring in paediatric medicine

    Wider context from the report

    “At the inquest the Paediatric Expert, ████████ gave the opinion that • The routine use of respiratory rate bench-markers in paediatric respiratory medicine • The use of routine oxygen blood monitoring in paediatric medicine • The recognition and action on red flag markers (which in this case were shortness of breath, chest pain and blue lips) Would have assisted and improved the chances of diagnosis and treatment of Esmee and other children, with a view to preventing future deaths or providing appropriate treatment and palliative care in life limiting cases. ”

    Source location

    Esmee Shayla Polmear · 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 routinely use respiratory rate benchmarks in paediatric respiratory medicine

    Wider context from the report

    “At the inquest the Paediatric Expert, ████████ gave the opinion that • The routine use of respiratory rate bench-markers in paediatric respiratory medicine • The use of routine oxygen blood monitoring in paediatric medicine • The recognition and action on red flag markers (which in this case were shortness of breath, chest pain and blue lips) Would have assisted and improved the chances of diagnosis and treatment of Esmee and other children, with a view to preventing future deaths or providing appropriate treatment and palliative care in life limiting cases. ”

    Source location

    Esmee Shayla Polmear · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  3. Inner South London

    AI-generated summary

    Archie Haxell · 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

    Archie Haxell was born by forceps delivery on 24 March 2013 and suffered a respiratory arrest about two hours after birth. He was transferred to St Thomas’ Hospital, where he died on 29 March 2013. The principal concerns were breakdowns in communication between healthcare professionals, failure to retain observation records, and failure to inform Archie’s parents about concerns regarding his breathing, contributing to delay in recognising his deteriorating condition.

    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 communicate possible signs of respiratory distress between midwives

    Wider context from the report

    “(1) About 25 minutes after his birth Archie was noted to be grunting and he then developed nasal flaring, both of which are potential signs of respiratory distress. He was ████████ performed a set of observations, including oxygen saturations and she also noticed vomiting, grunting and nasal flaring. The evidence at the inquest was that the observations on a piece of paper because the medical records were not immediately available (her observations were performed shortly after the birth of Archie’s brother who required resuscitation). Midwife ████████ later transcribed these results into the medical records. However, the evidence was that midwife ████████ was not aware of the vomiting, grunting and nasal flaring noticed by midwife ████████ although midwife ████████ believes she did pass this information on verbally. During this period may understandably have been focussed on Archie’s brother. However, I am concerned that the important information about further possible signs of respiratory distress was somehow lost in the communication between the two midwives. Also, the piece of paper on which the observations were recorded was not retained. I am concerned that this should have been retained in the medical records. ”

    Source location

    Archie Haxell · 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

    Embed SBAR communication and escalation across the maternity service and monitor progress through quarterly Quality and Safety Committee updates.

    Verbatim wording from the response

    “SBAR Work is currently underway to embed the use of this communication tool (Situation, Background, Assessment, Recommendation) within the maternity service. This is a simple tool used by many NHS organisations to ensure that communication between healthcare professionals is clear and concise, and to support effective escalation of situations when necessary.”

    Source location

    2015-0081-Response-by-Lewisham-Greenwich-NHS-Trust
    Page 3 · response
    Published 5 March 2015

    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

    Participate in the national Sign Up to Safety campaign through a Trust-wide initiative to reduce avoidable harm from failure to identify and act on deteriorating patients.

    Verbatim wording from the response

    “This technique is already underway in the Children’s Division, the Maternity Service, and has been incorporated into a wider Trust initiative under the umbrella of the national Sign Up To Safety campaign and our pledge to reduce harm to the ‘deteriorating patient’. Progress will be monitored at the Trust’s Quality and Safety Committee where quarterly updates will be presented by the pledge leads. This committee is chaired by the Trust’s Deputy Medical Director for Quality and Safety.”

    Source location

    2015-0081-Response-by-Lewisham-Greenwich-NHS-Trust
    Page 3 · response
    Published 5 March 2015

    Open published response

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

Back to top

Data last updated 7 September 2026