Recurring concern

Inadequate clinical competence to recognise and treat paediatric sepsis

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First reported 27 May 2016•Latest report 28 Feb 2020

Definition

What this concern includes

Includes failures of training, competence assessment, refresher provision, supervision or assurance for clinicians responsible for recognising, assessing or treating sepsis in babies, neonates, infants and children, including A&E consultants covering paediatric emergency care and staff responsible for neonatal or paediatric sepsis care.

Not included

  • Excludes generic sepsis-service, staffing or clinical-care deficiencies where paediatric or neonatal staff competence is not the unsafe condition.
  • Excludes failures in sepsis guidance content or consistency where staff competence is not the shared deficiency; these belong to guidance-specific concerns.
  • Excludes failures in recognition, investigation or treatment of sepsis after adequately competent staff and competence-assurance arrangements were in place.
  • Excludes adult-only sepsis competence concerns unless the assertion also explicitly concerns paediatric or neonatal sepsis care.
Reports
3

Distinct published reports

Individual concerns
4

A report can raise multiple concerns

Date range
2016–2020

First to latest report issue date

Stated actions
0

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.

NHS England2
Cardiff & Vale University LHB1
Care Quality Commission1
General Medical Council1
Liverpool University Hospitals NHS Foundation Trust1
NHS Cheshire and Merseyside Integrated Care Board1
NHS Cornwall and the Isles of Scilly Integrated Care Board1
Nursing and Midwifery Council1
Public Health England1
Royal Cornwall Hospital1

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. South Wales Central

    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

    Lack of competent A&E consultant knowledge and understanding for identifying and diagnosing sepsis in babies and very young children

    Wider context from the report

    “(1) A potential deficiency in the knowledge and understanding of A & E Consultants coving in the paediatric A & E Department (whilst there is no on site consultant in paediatric emergency medicine) in the identification/diagnosis of sepsis in babies and very young children. Whilst it is appreciated that the quest to recruit further consultants in paediatric emergency medicine to provide more comprehensive cover in the Department continues, until such time as a sufficient complement is in place, and A & E Consultants provide some of the cover, the Health Board must ensure that those that do, are urgently and adequately trained to a competent standard to deliver the care required. It cannot be simply left to the individual consultants to determine their own requirements in this regard. As their employers, the Health Board, has an overarching obligation to ensure that competent staff are employed and to maintain high professional standards. ”

    Source location

    Lewys Ryan Aidan CRAWFORD · 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

    Insufficient clinician and nurse use of the NICE Sepsis risk stratification tool for children aged under 5 years

    Wider context from the report

    “(2) There needs to be a greater understanding of, and reference to the NICE Sepsis risk stratification tool: children aged under 5 years in hospital by Clinicians and Nurses in both the A & E & Paediatric depts. Whilst it is appreciated that the finalisation of a bespoke sepsis tool, based upon the UK Sepsis Trust’s Tools and Pathways is awaited, until such time as its adopted, the Health Board needs to address apparent lapses in the understanding of what is required upon diagnosis of a potentially septic baby/child, particularly in the period between triage and admission to the ward. Specifically, the importance of stabilising the patient prior to transfer by completing a full septic screen. Furthermore, the Inquest highlighted gaps in the understanding and knowledge of agency nurses as to the septic screen and the steps to be followed. The Health Board needs a clear policy (and to ensure this is implemented & followed) to ensure that agency nurses are up to date with their training and understanding in this area of practice. ”

    Source location

    Lewys Ryan Aidan CRAWFORD · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Liverpool and the Wirral

    AI-generated summary

    Tom Cribley · 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

    Tom Cribley attended Aintree hospital on 18 February 2017 with vomiting, diarrhoea and a rash, and was later diagnosed with meningococcal sepsis. The report identifies concerns including failures to document and escalate the rash and deteriorating observations, inadequate handovers and reassessment, delayed recognition of abnormal blood results, and delayed antibiotic treatment. Tom did not recover and died on 20 February 2017.

    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

    Insufficient clinical staff training in identifying and treating sepsis

    Wider context from the report

    “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017. Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness. The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions. Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area. ”

    Source location

    Tom Cribley · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  3. Cornwall and Isles of Scilly

    AI-generated summary

    Charlie Mark Jermyn · 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

    Charlie Jermyn was born at home on 9 May 2015 and developed sleepiness, feeding difficulty and possible respiratory distress. He stopped breathing during a routine visit the following day and died in hospital despite resuscitation attempts. The principal concerns were delayed recognition and referral for suspected sepsis, inadequate telephone triage and recording, insufficient observations, and wider shortcomings in midwifery guidance, equipment and training.

    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

    Insufficient systemic, rigorous and regular neonatal sepsis training

    Wider context from the report

    “8. The red flag signs for sepsis (in this case sleepy, possible respiratory distress (grunting) and difficulty in feeding) were overlooked resulting in a fatal delay in referral to specialist hospital support/treatment. Identification of sepsis in new born babies is difficult and the staff and Trust should have had in place a systemic, rigorous and regular training in this area. The Trust's own clinical guidelines for the Prevention, Diagnosis and Treatment of Early Onset Neonatal Bacterial Infection, were not known to the midwives at the inquest. The Expert Midwife gave the opinion that the RCHT Trust guidelines were not consistent with the NICE guidance or best practice on this matter (page 14). In particular it was noted that capillary re-fill time should be undertaken and recorded in cases of suspected sepsis. ”

    Source location

    Charlie Mark Jermyn · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026