16 Jun 2022 James Joseph MANNING · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 14 Lack of a written procedure for making a 999 emergency call View source Lack of a national system for managing and sharing Health and Safety information across company sites View source Lack of guidance for urgent referral of children to hospital or tertiary care View source Lack of a written procedure for obtaining first aid help quickly View source Failure to provide adequately for visitors' first aid needs across sites View source Insufficient availability of AEDs in key site areas View source Lack of national guidance for consistent referral of children for tonsillectomy and similar treatment View source Failure to provide direct ENT referral or follow-up assessment after a child chokes View source Insufficiently robust incident investigation and reporting system View source Delays in reassessment and referral of urgent cases due to inadequate cover View source Inadequate systems for reviewing local information sharing View source Unavailability of an external phone line for emergencies View source Failure to communicate specialist referral priorities to local hospitals View source Absence of choking-related red flags in tonsillectomy guidance View source See 11 more concerns
Responses linked to these concerns
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James Joseph MANNING · 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
James Joseph Manning, aged two, choked on a piece of sausage at Butlins, Bognor Regis, on 6 June 2018, suffered a cardiac arrest and hypoxic ischaemic brain injury, and died in hospital on 20 June 2018. The concerns included delays and weaknesses in healthcare referral, follow-up and information-sharing systems, and shortcomings in the management of health and safety, incident reporting, first-aid provision and emergency procedures at Bourne Leisure sites.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bourne Leisure Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of a written procedure for making a 999 emergency call
Wider context from the report “e) Witnesses confirmed that there was no written standard operating procedure setting out how staff can get first aid help quickly as well as when and how to make a 999-emergency call especially if a trained first aider is not immediately available.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bourne Leisure Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of a national system for managing and sharing Health and Safety information across company sites
Wider context from the report “a) From speaking to a number of witnesses in this case, I was deeply concerned that there was no national system for managing Health & Safety issues across company sites . Staff agreed it would help to share information and learning on a reciprocal basis across all sites .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bourne Leisure Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for urgent referral of children to hospital or tertiary care
Wider context from the report “a) I heard expert evidence that GPs and general hospital doctors would benefit from national guidance to ensure that greater consistency is achieved when referring children for tonsillectomy and similar treatment. In addition, both GP and hospital doctors gave evidence that raised a concern regarding:
i. whether additional guidance may be appropriate to help doctors decide which cases need an urgent referral to hospital or tertiary care ; and
ii. a system of red flags – for example including choking in the ENT UK Commissioning Guide for Tonsillectomy (2016). Experts and witnesses confirmed that choking is not mentioned in the current Guide.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bourne Leisure Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of a written procedure for obtaining first aid help quickly
Wider context from the report “e) Witnesses confirmed that there was no written standard operating procedure setting out how staff can get first aid help quickly as well as when and how to make a 999-emergency call especially if a trained first aider is not immediately available .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bourne Leisure Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to provide adequately for visitors' first aid needs across sites
Wider context from the report “c) I am concerned that the Health & Safety Executive’s strong recommendation in the First Aid Regulations to consider the first aid of visitors and what will be offered in terms of provision across each site was not sufficiently reflected in company practices .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bourne Leisure Limited; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of AEDs in key site areas
Wider context from the report “d) I was concerned to hear evidence that many months after this tragic incident during Tots Week, installation of an external phone line and sufficient AEDs in key areas such as restaurants and swimming pool areas had not been completed .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bourne Leisure Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance for consistent referral of children for tonsillectomy and similar treatment
Wider context from the report “a) I heard expert evidence that GPs and general hospital doctors would benefit from national guidance to ensure that greater consistency is achieved when referring children for tonsillectomy and similar treatment . In addition, both GP and hospital doctors gave evidence that raised a concern regarding:
i. whether additional guidance may be appropriate to help doctors decide which cases need an urgent referral to hospital or tertiary care; and
ii. a system of red flags – for example including choking in the ENT UK Commissioning Guide for Tonsillectomy (2016). Experts and witnesses confirmed that choking is not mentioned in the current Guide.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bourne Leisure Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to provide direct ENT referral or follow-up assessment after a child chokes
Wider context from the report “b) I also heard evidence from experts that when a child chokes as James did in May 2017, the risk of a life-threatening event is high. I was concerned to hear that A&E paediatricians could either refer directly to ENT specialists or arrange a follow-up visit to assess the likelihood of a repeat choking episode but in this case the child’s mother was referred back to the GP .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bourne Leisure Limited; that does not assign responsibility.
PFD Monitor interpretation Insufficiently robust incident investigation and reporting system
Wider context from the report “b) After hearing extensive evidence, I was deeply concerned about whether there was a sufficiently robust incident investigation and reporting system in place so that lessons could be learned then shared with staff .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bourne Leisure Limited; that does not assign responsibility.
PFD Monitor interpretation Delays in reassessment and referral of urgent cases due to inadequate cover
Wider context from the report “c) I heard evidence that at some points in James’s medical care there were delays in being reassessed especially following the sleep study . The delay in being reassessed and referred to tertiary care was contributed to by medical staff being off leave. Doctors will inevitably have leave yet I am still concerned that systems in place at that time were not sufficiently robust to ensure suitable cover was in place to progress urgent cases .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bourne Leisure Limited; that does not assign responsibility.
PFD Monitor interpretation Inadequate systems for reviewing local information sharing
Wider context from the report “f) At several points during the inquest, questions were asked of medical witnesses about how best practice is shared between local NHS Trusts and GP surgeries. I am concerned that systems to review how information is shared locally may need to be reconsidered .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bourne Leisure Limited; that does not assign responsibility.
PFD Monitor interpretation Unavailability of an external phone line for emergencies
Wider context from the report “d) I was concerned to hear evidence that many months after this tragic incident during Tots Week, installation of an external phone line and sufficient AEDs in key areas such as restaurants and swimming pool areas had not been completed .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bourne Leisure Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate specialist referral priorities to local hospitals
Wider context from the report “d) I also heard evidence to suggest that locally devised priorities agreed in specialist or tertiary centres (in this case the Royal Sussex County Hospital, Brighton) had not been communicated to local hospitals and shared so that doctors making a referral can consider the best place to refer a case taking into consideration relative waiting times .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bourne Leisure Limited; that does not assign responsibility.
PFD Monitor interpretation Absence of choking-related red flags in tonsillectomy guidance
Wider context from the report “a) I heard expert evidence that GPs and general hospital doctors would benefit from national guidance to ensure that greater consistency is achieved when referring children for tonsillectomy and similar treatment. In addition, both GP and hospital doctors gave evidence that raised a concern regarding:
i. whether additional guidance may be appropriate to help doctors decide which cases need an urgent referral to hospital or tertiary care; and
ii. a system of red flags – for example including choking in the ENT UK Commissioning Guide for Tonsillectomy (2016). Experts and witnesses confirmed that choking is not mentioned in the current Guide .
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations