4 Mar 2026 Viviana-Ray Winnie Elsie Wendy Butnaru · Prevention of Future Deaths report Essex
View report summary
Concerns raised 6 Lack of awareness of the difference between metabolic and respiratory acidosis View source Failure to fully explore underlying causes of metabolic acidosis View source Delays in official radiologist reporting of chest X-rays showing cardiomegaly View source Lack of guidelines for identifying and investigating possible heart-related issues in accident and emergency and paediatric settings View source Incomplete recording of medical-team handovers View source Incomplete documentation of nursing observations and escalations View source See 3 more concerns
Responses linked to these concerns
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AI-generated summary
Viviana-Ray Winnie Elsie Wendy Butnaru · 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
Viviana-Ray Winnie Elsie Wendy Butnaru attended the Children’s Emergency Department on 24 October 2024 and died at Basildon Hospital on 25 October 2024 after cardiac arrest. The stated cause of death was myocarditis caused by Parvovirus, contributed to by bronchiolitis and bronchopneumonia. Concerns included delayed reporting of chest X-rays showing cardiomegaly, incomplete exploration of metabolic acidosis, failures in escalation and review processes, and incomplete documentation and handovers.
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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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness of the difference between metabolic and respiratory acidosis
Wider context from the report “(4) Underlying causes for metabolic acidosis were not fully explored. Greater awareness of the difference between metabolic and respiratory acidosis is required .
” 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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Failure to fully explore underlying causes of metabolic acidosis
Wider context from the report “(4) Underlying causes for metabolic acidosis were not fully explored . Greater awareness of the difference between metabolic and respiratory acidosis is required.
” 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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Delays in official radiologist reporting of chest X-rays showing cardiomegaly
Wider context from the report “(3) Chest X rays which showed cardiomegaly were not reported officially by a radiologist until several days later .
” 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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Lack of guidelines for identifying and investigating possible heart-related issues in accident and emergency and paediatric settings
Wider context from the report “(1) There appears to be a lack of local or national guidelines assisting those assessing patients in an accident and emergency and paediatric environment to assess the correct pathway for identifying and investigating those who may present with heart related issues such as myocarditis .
” 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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Incomplete recording of medical-team handovers
Wider context from the report “(5) Incomplete documentation to be addressed to include all updates from nursing staff in relation to observations and escalations; and handovers from the medical team to one another to be clearly recorded .
” 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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Incomplete documentation of nursing observations and escalations
Wider context from the report “(5) Incomplete documentation to be addressed to include all updates from nursing staff in relation to observations and escalations ; and handovers from the medical team to one another to be clearly recorded.
” Open source report
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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 Formal chest X-ray reporting delays lie outside the respondent’s control.
Verbatim wording from the response “• Chest X ray reporting. This lies outside of our control but we recognise that there is often some delay between images being taken in the context of an emergency and a formal report being issued. All clinicians have some training in interpreting chest X rays.” Source location Response from The Royal College of Paediatrics and Child Health
Open published response
Concerns raised 1 Failure to maintain contemporaneous, accurate and immediately available documentation of external calls between community and hospital teams View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Alfie Lydon · 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
Alfie Lydon was admitted to hospital after being found profoundly unwell at home, transferred for intensive care, and died from the consequences of a viral infection. Before admission, his parents had raised concerns about his feeding and increasing lethargy, and discussions between midwives and the neonatal team were not consistently documented. The report raised concern that inadequate, contemporaneous documentation of discussions between community and hospital teams could affect continuity and escalation of care and result in future deaths in similar circumstances.
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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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain contemporaneous, accurate and immediately available documentation of external calls between community and hospital teams
Wider context from the report “1. I heard evidence that the vast majority of hospital Trusts do not have processes in place to document external calls from midwives to hospital teams . Concerns were raised that this can result in a lack of continuity and escalation of care, particularly with regards to parental concerns.
The hospital Trust involved has taken steps to document such calls now but this is undertaken on paper, which is subsequently uploaded to the hospital records. They plan to implement an electronic solution but not for some time.
There is a concern that a lack of contemporaneous, accurate and immediately available documentation of discussions between community and hospital teams could result in deaths in future similar circumstances. Given that this is not simply a local issue, this concern warrants raising at a national level.
” Open source report
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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 Direct control over how healthcare staff record clinical communications lies outside the organisation’s authority as a membership body.
Verbatim wording from the response “As a membership organisation we have no direct control over the mechanism(s) by which healthcare staff record their clinical communications. Our sphere of influence lies in nudging change at national level. Currently, there is a lack of legislation and guidance on exactly what information, when and how it should be shared between agencies. In practice, our members (paediatricians) have reported difficulties in exchanging information, which may be a result of poor communication between professionals and/or a lack of interoperable information systems available to effectively share information. Use of the NHS number as a single unique identifier for children will overcome these barriers and enable information to be shared more easily between agencies and services.” Source location Response from Royal College of Paediatrics and Child Health
Open published response
Concerns raised 3 Lack of paediatric nursing observations View source Failure of medical staff to recognise absent nursing observations View source Failure to complete final nursing observations before discharge View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Finlay Joshua ROBERTS · 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
Finlay’s parents took him to Whittington Hospital the night before he died, during an extremely busy and understaffed night in the paediatric emergency department. The report describes failures to conduct serial nursing observations, complete appropriate tests, and obtain specialist advice before Finlay was discharged home. The principal concerns were that missing nursing observations may be a wider issue and that medical staff failed to recognise that the observations had not been carried out.
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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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Lack of paediatric nursing observations
Wider context from the report “The lack of serial nursing observations was a fundamental omission from Finlay’s care. I heard at inquest that there have been many improvements in the paediatric emergency department at the Whittington since his death, not least of which has been the addition of more nursing staff.
However, a lack of paediatric nursing observations is a subject about which I wrote a PFD report on 13 March 2025 to a different hospital (the Royal Free) following the death of Billie Wicks.
I remain concerned on two counts:
1. A lack of nursing observations may be a much wider issue than is recognised. In my experience there is nothing about the Whittington and the Royal Free that stands out as unusual.
2. The medical staff at the Whittington did not recognise the lack of nursing observations.
• Observations were thought to be acceptable because they were not reported as otherwise, when in fact they were absent.
• The discharging doctor decided that, if his final observations were normal Finlay could go home. Those observations were never carried out, but Finlay was nevertheless discharged.
” 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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Failure of medical staff to recognise absent nursing observations
Wider context from the report “The lack of serial nursing observations was a fundamental omission from Finlay’s care. I heard at inquest that there have been many improvements in the paediatric emergency department at the Whittington since his death, not least of which has been the addition of more nursing staff.
However, a lack of paediatric nursing observations is a subject about which I wrote a PFD report on 13 March 2025 to a different hospital (the Royal Free) following the death of Billie Wicks.
I remain concerned on two counts:
1. A lack of nursing observations may be a much wider issue than is recognised. In my experience there is nothing about the Whittington and the Royal Free that stands out as unusual.
2. The medical staff at the Whittington did not recognise the lack of nursing observations.
• Observations were thought to be acceptable because they were not reported as otherwise, when in fact they were absent.
• The discharging doctor decided that, if his final observations were normal Finlay could go home. Those observations were never carried out, but Finlay was nevertheless discharged.
” 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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Failure to complete final nursing observations before discharge
Wider context from the report “The lack of serial nursing observations was a fundamental omission from Finlay’s care. I heard at inquest that there have been many improvements in the paediatric emergency department at the Whittington since his death, not least of which has been the addition of more nursing staff.
However, a lack of paediatric nursing observations is a subject about which I wrote a PFD report on 13 March 2025 to a different hospital (the Royal Free) following the death of Billie Wicks.
I remain concerned on two counts:
1. A lack of nursing observations may be a much wider issue than is recognised. In my experience there is nothing about the Whittington and the Royal Free that stands out as unusual.
2. The medical staff at the Whittington did not recognise the lack of nursing observations.
• Observations were thought to be acceptable because they were not reported as otherwise, when in fact they were absent.
• The discharging doctor decided that, if his final observations were normal Finlay could go home. Those observations were never carried out, but Finlay was nevertheless discharged.
” Open source report
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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 Revise and update emergency-care standards to clarify observations as holistic care, including frequency determined by the child’s wellbeing.
Verbatim wording from the response “The RCPCH Facing the Future Standards for Emergency Care ensure that urgent and emergency care is fully integrated to ensure children are seen by the right people, at the right place and in the right setting. We are currently in the process of audit, review and revision and update of these standards, to be published later in 2025. The revised version will set out that observations are part of holistic care and repetition is dependent on the child’s well-being, alongside clarification around frequency of observations. This update has been led by an Intercollegiate Committee for Emergency Care, including representation from the Royal College of Nursing.” Source location 2025-0316 Response from Royal College of Paediatrics and Child Health
Open published response
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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 Continue advocating locally and nationally for active reduction of paediatric staffing rota gaps.
Verbatim wording from the response “As we noted then, observations are important but are part of a holistic assessment of children. There are lots of reasons why observations might not be obtained, and RCPCH recognises that challenges in adequately staffing emergency departments may be one reason. In 2024, RCPCH carried out work to better understand where rota gaps most prominently impact on paediatric staffing, and we continue to advocate at a local and national level for an active reduction in these gaps.” Source location 2025-0316 Response from Royal College of Paediatrics and Child Health
Open published response
3 Jun 2025 Benjamin Finch Arnold · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 6 Unequal provision of maternity services between LGI and SJUH View source Ambiguity about the classification and operating parameters of the SJUH maternity unit View source Limited nursing and medical support available to the SJUH site View source Lack of standardised guidelines for performing LISA procedures View source Insufficient national guidelines for identifying and treating reversible causes of cardiac arrest in newborn babies View source Lack of on-site paediatric cover at SJUH View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Benjamin Finch Arnold · 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
Benjamin Finch Arnold was born prematurely at Saint James’ University Hospital after his mother was redirected there because the intended delivery unit was closed due to lack of capacity. He developed breathing difficulties during a LISA procedure, suffered bilateral pneumothoraces and a subsequent right-sided tension pneumothorax, and died after a devastating brain injury caused by prolonged low oxygen levels. The concerns included the organisation and classification of maternity services, the lack of standardised guidance for LISA procedures and newborn cardiac arrest, and updates to the hospital risk register.
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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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Unequal provision of maternity services between LGI and SJUH
Wider context from the report “(1) The provision of maternity services across the Leeds Teaching Hospitals Trust (LTHT) continues to be split unequally between LGI and SJUH , with, for example, no on-site paediatric cover at SJUH. What was described by LTHT witnesses as the “isolation” of the SJUH site, particularly as it related to the limited nursing and medical support that can be called upon, was a recurrent theme in the inquest. The inquest was told that a long held ambition to bring LTHT’s maternity services under one roof had been recently frustrated by the announcement that the building of a new hospital for Leeds would not begin until 2030. Secretary of State for Health and Social Care to respond.
” 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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Ambiguity about the classification and operating parameters of the SJUH maternity unit
Wider context from the report “(2) The evidence at the inquest disclosed an ambiguity as to whether the SJUH maternity unit, officially a “Level 1” centre, was operating outside the parameters of that classification . That ambiguity was demonstrated by a witness (whose evidence was admitted in writing under R23 due to her poor health) who described it as a “Level 2” unit , and by a witness in person who described it as a “Level 1 and a half” unit, which last classification does not exist . LTHT to respond.
” 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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Limited nursing and medical support available to the SJUH site
Wider context from the report “(1) The provision of maternity services across the Leeds Teaching Hospitals Trust (LTHT) continues to be split unequally between LGI and SJUH, with, for example, no on-site paediatric cover at SJUH. What was described by LTHT witnesses as the “isolation” of the SJUH site, particularly as it related to the limited nursing and medical support that can be called upon , was a recurrent theme in the inquest. The inquest was told that a long held ambition to bring LTHT’s maternity services under one roof had been recently frustrated by the announcement that the building of a new hospital for Leeds would not begin until 2030. Secretary of State for Health and Social Care to respond.
” 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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Lack of standardised guidelines for performing LISA procedures
Wider context from the report “(3) The evidence disclosed concerns that guidelines for the performing of a LISA procedure are not standardised across the NHS , particularly with reference to the performing of a chest x-ray to exclude pneumothorax before commencing the procedure , and to the necessity of seeking consultant approval before undertaking the procedure . BAPM, RCPCH, RCUK and NN all to respond.
” 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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Insufficient national guidelines for identifying and treating reversible causes of cardiac arrest in newborn babies
Wider context from the report “(4) The evidence disclosed concerns whether national guidelines on the reversible causes of cardiac arrest (the “4 H’s and 4 T’s”) were sufficient for the purposes of identifying and treating the potential causes of cardiac arrest in a newborn baby . BAPM, RCPCH, RCUK and NN all to respond.
” 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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Lack of on-site paediatric cover at SJUH
Wider context from the report “(1) The provision of maternity services across the Leeds Teaching Hospitals Trust (LTHT) continues to be split unequally between LGI and SJUH, with, for example, no on-site paediatric cover at SJUH . What was described by LTHT witnesses as the “isolation” of the SJUH site, particularly as it related to the limited nursing and medical support that can be called upon, was a recurrent theme in the inquest. The inquest was told that a long held ambition to bring LTHT’s maternity services under one roof had been recently frustrated by the announcement that the building of a new hospital for Leeds would not begin until 2030. Secretary of State for Health and Social Care to respond.
” Open source report
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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 Standardised LISA procedure guidance is outside the respondent’s remit because it does not produce such guidance.
Verbatim wording from the response “RCPCH does not produce standardised guidance for Less Invasive Surfactant Administration (LISA) procedures. We note that NICE Quality Standard QS193 recommends the use of LISA and that NHS England are responsible for commissioning services which support this technique. RCPCH would suggest that the views of the British Association of Perinatal Medicine (BAPM), who are the experts in care for this cohort of children, are considered and shared with NHS England regarding standardised guidelines.” Source location Response from Royal College of Paediatrics and Child Health
Open published response
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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 BAPM and RCUK should determine whether changes to neonatal use of the 4 H’s and 4 T’s guidance are required.
Verbatim wording from the response “The 4 H’s and 4 T’s guidelines are owned by the Resuscitation Council UK (RCUK), and RCPCH expects members to follow this guidance. Given the specificity of the concern with regard to use of these guidelines in neonatology, RCPCH would defer to BAPM and RCUK to pool their expertise on this matter in order to determine whether any changes are required.” Source location Response from Royal College of Paediatrics and Child Health
Open published response
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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 England is responsible for commissioning services supporting LISA, while BAPM’s expert views should inform standardised guidance.
Verbatim wording from the response “RCPCH does not produce standardised guidance for Less Invasive Surfactant Administration (LISA) procedures. We note that NICE Quality Standard QS193 recommends the use of LISA and that NHS England are responsible for commissioning services which support this technique. RCPCH would suggest that the views of the British Association of Perinatal Medicine (BAPM), who are the experts in care for this cohort of children, are considered and shared with NHS England regarding standardised guidelines.” Source location Response from Royal College of Paediatrics and Child Health
Open published response
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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 The 4 H’s and 4 T’s guidance is owned by RCUK, so changes to it are outside the respondent’s authority.
Verbatim wording from the response “The 4 H’s and 4 T’s guidelines are owned by the Resuscitation Council UK (RCUK), and RCPCH expects members to follow this guidance. Given the specificity of the concern with regard to use of these guidelines in neonatology, RCPCH would defer to BAPM and RCUK to pool their expertise on this matter in order to determine whether any changes are required.” Source location Response from Royal College of Paediatrics and Child Health
Open published response
13 May 2025 Rose Annie Harfleet · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 4 Failure to routinely obtain and listen to parents’ or guardians’ information about children with profound disabilities View source Lack of guidance for managing children with profound disabilities in hospital settings View source Failure to recognise and act on parents’ ongoing concerns about children on hospital wards View source Failure to routinely offer learning disability liaison nurse support in the emergency department View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Rose Annie Harfleet · 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
Rose Annie Harfleet, aged 12, died in hospital on 30 January 2024 after presenting with abdominal pain and vomiting, later identified as a caecal volvulus causing intestinal obstruction and bowel ischaemia. The report raised concerns about failures to recognise and respond to her deterioration, obtain and act on information from her mother, provide appropriate monitoring and surgical review, and offer learning disability liaison support. It also identified a lack of guidance for managing and consulting with children with profound disabilities in hospital settings.
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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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely obtain and listen to parents’ or guardians’ information about children with profound disabilities
Wider context from the report “2. Guidelines - consultation with parents and guardians of children with profound disabilities within a hospital setting
Rose’s mother was devoted to Rose and was very able to advocate on Rose’s behalf as well as being best placed to provide the vital information about her signs and symptoms given Rose was unable to do this for herself. The importance of obtaining this information was not understood by the paediatric consultant who took no history from Rose’s mother and underestimated the severity of her signs and symptoms. The consequence of this was that Rose’s voice – through her mother as her advocate – was not heard and she was not therefore able to actively participate in the care and management that was provided to Rose, the corollary of which resulted in poor clinical decision making which contributed to Rose’s death. This gives rise to a concern that by not listening to parents or guardians as a matter of course leads to discrimination of disabled children.
” 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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for managing children with profound disabilities in hospital settings
Wider context from the report “1. The management of children with profound disabilities within a hospital setting
Rose was a deeply loved child who brought great joy to her mother, wider family and all that knew her. During the inquest hearing no national or local guidance was forthcoming to assist medical and nursing staff, within a conventional hospital setting, to appropriately manage patients such as Rose who had a global developmental delay and was wholly reliant on her mother to advocate on her behalf . This gives rise to a concern that this omission adversely impacts the care that patients such as Rose receive.
” 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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise and act on parents’ ongoing concerns about children on hospital wards
Wider context from the report “3. Nursing and Medical care on the ward
In the absence of local and national guidelines, the importance of listening and responding to Rose’s mothers ongoing concerns about her daughter when she was transferred to the ward were not recognised by the nursing and medical staff and consequently not acted upon thereby contributing to Rose’s death. There appears to be a prevailing culture that in the absence of a patient being able to explain their symptoms themselves the voice of the parent or guardian is not given the significance it should be for the most vulnerable in a hospital setting.
” 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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely offer learning disability liaison nurse support in the emergency department
Wider context from the report “4. LeDeR Role
Rose’s admission was during the working week, yet there was no consideration or offer given to Rose or her mother during her time in the Emergency Department to being introduced to a learning Disability Liaison Nurse . This led to Rose’s mother being unsupported during this admission or for a nursing professional to be able to liaise and advocate for Rose and her mother with medical and nursing staff in the emergency department. This again gives rise to a concern that patients such as Rose and her mother are adversely impacted on the care that they receive in the absence of local and national guidelines that this should be routinely available and offered as a matter of course.
” Open source report
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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 Collaborate with NHS England and the Royal College of Nursing to develop a single national Paediatric Early Warning System for England.
Verbatim wording from the response “In addition, RCPCH are committed to the introduction, embedding and appropriate standardisation of Paediatric Early Warning Systems (PEWS) within the four nations. PEWS are designed to effectively recognise and respond to the deterioration of children or young people in a healthcare environment. A parental escalation process is essential to any effectively PEWS. We have been collaborating with NHS England and the Royal College of Nursing to develop a single national PEWS for England since 2018 and are supportive of equivalent processes across the UK.” Source location Response from Royal College of Paediatrics
Open published response
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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 Revise and update the Facing the Future: Emergency Care Standards.
Verbatim wording from the response “The RCPCH Facing the Future standards describe how paediatric care should be delivered to provide a safe and sustainable, high-quality service that meets the health needs of every child and young person. Our Facing the Future: Emergency Care Standards apply to all persons up until the age of 18. These standards aim to ensure that urgent and emergency care is fully integrated to ensure children are seen by the right people, at the right place and in the right setting. We are currently in the process of review, revision and update of our current standards, to be published in Autumn 2025.” Source location Response from Royal College of Paediatrics
Open published response
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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 Publish the revised Facing the Future: Emergency Care Standards in Autumn 2025.
Verbatim wording from the response “The RCPCH Facing the Future standards describe how paediatric care should be delivered to provide a safe and sustainable, high-quality service that meets the health needs of every child and young person. Our Facing the Future: Emergency Care Standards apply to all persons up until the age of 18. These standards aim to ensure that urgent and emergency care is fully integrated to ensure children are seen by the right people, at the right place and in the right setting. We are currently in the process of review, revision and update of our current standards, to be published in Autumn 2025.” Source location Response from Royal College of Paediatrics
Open published response
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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 Share the revised standards with professionals working in emergency care settings.
Verbatim wording from the response “The revised standards are due to be published in Autumn 2025 and will be shared with all relevant professionals working in emergency care settings. I will share your report with the Chair of our Intercollegiate Committee for Emergency Care who is leading this work for their information.” Source location Response from Royal College of Paediatrics
Open published response
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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 Support rollout of Martha’s Rule and engage with NHS England as pilot data emerge.
Verbatim wording from the response “RCPCH are actively supporting the role out of Martha’s Rule. Martha’s Rule is a patient safety initiative currently being piloted in England which aims to empower all staff, patients and their families to seek an independent medical review if they feel their concerns about a patient’s care are not being adequately addressed. The rule is designed to give families the ability to directly request an expert review by a senior clinician not within the immediate care team, potentially identifying critical issues before they result in harm.” Source location Response from Royal College of Paediatrics
Open published response
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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 Provision of nursing care and access to learning disability liaison nurses fall outside the respondent’s authority.
Verbatim wording from the response “Good medical practice, produced by the General Medical Council, sets out the principles, values, and standards of professional behaviour expected of all doctors. This includes requirements that doctors must “treat all patients fairly and without discrimination, including those with disabilities” and that “doctors are required to consider and respond to the communication needs of all patients, including those with disabilities.” RCPCH has no authority over provision of nursing care on wards but notes that the Nursing and Midwifery Council states how nurses “must take account of individual differences, capabilities and needs” and “use a range of communication skills and technologies to support person-centred care and enhance quality and safety”.” Source location Response from Royal College of Paediatrics
Open published response
Concerns raised 6 Understaffing of the emergency department, including insufficient staff to take basic observations View source Failure to perform hourly observations in the emergency department View source Failure to administer the first antibiotic dose in the emergency department View source Lack of training or guidance on adult-onset asthma View source Safety-netting advice failing to provide a meaningful instruction when patients have already sought help for the same concern View source Failure to include blood pressure in the national paediatric early warning score View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Billie Diane WICKS · 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
Billie Wicks, aged 16, was brought to hospital with an asthma attack and was discharged without adequate repeat observations or senior clinical review. The report states that her asthma was not diagnosed or treated and that she died from infective exacerbation of asthma. Concerns included understaffing and inadequate observations, delayed antibiotic treatment, lack of awareness of adult-onset asthma, and the limitations of safety-netting advice after her parents had already sought hospital care.
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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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Understaffing of the emergency department, including insufficient staff to take basic observations
Wider context from the report “1. At inquest, I heard repeatedly that on the night Billie attended, the Royal Free emergency department was understaffed, and that it remains understaffed of doctors, nurses, and even a healthcare assistant who could take basic observations .
Billie should have had observations every hour. If she had had these observations, the emergency registrar who discharged her would have recognised that she was not as well as he thought, and would have sought senior medical review. That senior medical review would have changed the course of her management and saved her life.
Following the inquest touching on the death of Daniel Klosi, I wrote to you on 16 August 2024 about a lack of observations in the emergency department of the Royal Free. Although the circumstances were different, there is a theme.
” 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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Failure to perform hourly observations in the emergency department
Wider context from the report “1. At inquest, I heard repeatedly that on the night Billie attended, the Royal Free emergency department was understaffed, and that it remains understaffed of doctors, nurses, and even a healthcare assistant who could take basic observations.
Billie should have had observations every hour . If she had had these observations, the emergency registrar who discharged her would have recognised that she was not as well as he thought, and would have sought senior medical review. That senior medical review would have changed the course of her management and saved her life.
Following the inquest touching on the death of Daniel Klosi, I wrote to you on 16 August 2024 about a lack of observations in the emergency department of the Royal Free . Although the circumstances were different, there is a theme.
” 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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Failure to administer the first antibiotic dose in the emergency department
Wider context from the report “2. The registrar who saw Billie the night before her death prescribed an antibiotic, but he was not in the habit of giving the first dose in the department and he did not on this occasion . This meant that Billie’s infection was not tackled as quickly as it could have been. This seems to indicate a training and potentially a guideline need.
” 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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Lack of training or guidance on adult-onset asthma
Wider context from the report “3. At the time of Billie’s presentation, the registrar was unaware of the possibility of adult onset asthma . This seems to indicate a training and potentially a guideline need .
” 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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Safety-netting advice failing to provide a meaningful instruction when patients have already sought help for the same concern
Wider context from the report “4. I heard that Billie was safely netted when she was discharged. Her parents were told to bring her back if they had any concerns.
I have heard this safety netting advice being described many, many times in different inquests. What worries me about it in this context is that Billie’s parents had brought her to hospital because they were concerned. They were then reassured by hospital staff. It is therefore difficult to see how this particular advice could be a meaningful instruction.
In reality, her parents’ initial concern was well placed and they had responded to it appropriately by bringing Billie to hospital. When Billie began to deteriorate again, her parents’ natural instinct had been blunted by their first visit to the hospital.
” 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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Failure to include blood pressure in the national paediatric early warning score
Wider context from the report “5. Whilst I doubt that it would have made a difference in this case, I understand that blood pressure is not yet an observation included in the national paediatric early warning score (PEWS) .
” Open source report
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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 Include blood pressure as an observation in the national paediatric early warning score.
Verbatim wording from the response “I can confirm that blood pressure is now an observation included in the national paediatric early warning score (PEWS). The PEWS score consists of: Heart Rate, Respiratory Rate, Extent of Respiratory Distress, Blood Pressure, Oxygen Saturation, Oxygen Delivery and Capillary Refill Time (CRT).” Source location Response from Royal College of Paediatrics and Child Health
Open published response
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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 Continue advocating locally and nationally for active reduction of paediatric rota gaps.
Verbatim wording from the response “From the information provided we do not know many observations (if any) Billie had during her five hour stay in ED. Observations are important but are part of a holistic assessment of children. There are lots of reasons why observations might not be obtainable, however RCPCH recognises that challenges are significantly exacerbated by gaps in clinical rotas resulting in understaffed departments. In 2024, RCPCH carried out work to better understand where rota gaps most prominently impact paediatrics, and we continue to advocate at a local and national level for an active reduction in these gaps¹.” Source location Response from Royal College of Paediatrics and Child Health
Open published response
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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 Collaborate with NHS England and the Royal College of Nursing to develop a single national PEWS for England.
Verbatim wording from the response “RCPCH have been collaborating with NHS England and the Royal College of Nursing to develop a single national PEWS for England since 2018 and are supportive of equivalent processes across the UK.” Source location Response from Royal College of Paediatrics and Child Health
Open published response
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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 Conducted work to identify where paediatric rota gaps most significantly affect services.
Verbatim wording from the response “From the information provided we do not know many observations (if any) Billie had during her five hour stay in ED. Observations are important but are part of a holistic assessment of children. There are lots of reasons why observations might not be obtainable, however RCPCH recognises that challenges are significantly exacerbated by gaps in clinical rotas resulting in understaffed departments. In 2024, RCPCH carried out work to better understand where rota gaps most prominently impact paediatrics, and we continue to advocate at a local and national level for an active reduction in these gaps¹.” Source location Response from Royal College of Paediatrics and Child Health
Open published response
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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 Audit, review, revise and update emergency care standards, with publication planned for later 2025.
Verbatim wording from the response “Standards apply to all persons up until the age of 18, regardless of where they are treated. These standards aim to ensure that urgent and emergency care is fully integrated to ensure children are seen by the right people, at the right place and in the right setting.
We are currently in the process of audit, review and revision and update of our current standards, to be published later in 2025.” Source location Response from Royal College of Paediatrics and Child Health
Open published response
Concerns raised 1 Lack of compulsory direct observed training for paediatric middle grades performing neonatal intubation View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Yahya Muhammad Hayat · 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
Yahya Muhammad Hayat was born at Tameside Hospital on 12 April 2024 following a maternal uterine rupture and severe hypoxic-ischaemic encephalopathy, and died at Royal Oldham Hospital on 25 April 2024 after compassionate care was commenced and he was extubated. The inquest identified concerns about the lack of continuous monitoring and delays in medical review and decision-making before delivery, as well as changes to paediatric specialist training for neonatal intubation.
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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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Lack of compulsory direct observed training for paediatric middle grades performing neonatal intubation
Wider context from the report “The court heard evidence of changes to paediatric specialist training that has removed the requirement that paediatric middle grades undergo compulsory direct observed training to be assessed as competent to perform neonatal intubation .
The following matters of concern arise from this :
(1) The fact training is no longer compulsory, increases the reliance on consultants ( who in some clinical settings may be non-resident on call depending when delivery takes place) ; and
(2) Consultant general paediatricians of the future will have a lower level of experience than is currently the case of complex neonatal resuscitation
” Open source report
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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 neonatal airway management training through Progress+ neonatology placements.
Verbatim wording from the response “The Progress+ curriculum for paediatrics provides placements in neonatology between ST1-4, providing opportunities to develop knowledge and practical skills. Historically, training in safe airway management and intubation has taken place on neonatal placements and this will carry on during Progress+.” Source location Response from RCPCH
Open published response
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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 Strengthen the Progress+ curriculum's neonatal airway capabilities, emphasizing non-invasive airway management and specialty-level safe intubation and difficult-airway management.
Verbatim wording from the response “As noted in the report, with the introduction of the new Progress+ curriculum, the requirements for a mandatory successful DOPS (direct observation of procedural skills) for neonatal intubation has been removed, however key capabilities to manage a neonatal airway safely have been broadened and strengthened. This is in line with current evidence that in most cases a neonatal airway can be maintained more safely and reliably with non-invasive techniques, especially in inexperienced hands.” Source location Response from RCPCH
Open published response
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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 a neonatal airway safety standard with BAPM addressing skills maintenance and ongoing training.
Verbatim wording from the response “We have also worked with the British Association of Perinatal Medicine, BAPM, to develop a neonatal airway safety standard that aligns with our curriculum. There is a very clear focus in this document on maintaining skills and ongoing training, and the document contains several resources (log books, multiprofessional simulations etc). to support professionals with the maintenance of skills. We will ensure we are signposting our members to this resource accordingly.” Source location Response from RCPCH
Open published response
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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 Signpost members to the neonatal airway safety standard and its skills-maintenance resources.
Verbatim wording from the response “We have also worked with the British Association of Perinatal Medicine, BAPM, to develop a neonatal airway safety standard that aligns with our curriculum. There is a very clear focus in this document on maintaining skills and ongoing training, and the document contains several resources (log books, multiprofessional simulations etc). to support professionals with the maintenance of skills. We will ensure we are signposting our members to this resource accordingly.” Source location Response from RCPCH
Open published response
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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 Removing mandatory neonatal intubation DOPS does not necessarily increase risk because non-invasive airway management is safer and the former DOPS provided false reassurance.
Verbatim wording from the response “1. The fact training [specifically compulsory direct observed training to be assessed as competent to perform neonatal intubation] is no longer compulsory, increases the reliance on consultants (who in some clinical settings may be non-resident on call depending on when delivery takes place)” Source location Response from RCPCH
Open published response
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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 Operational delivery networks are responsible for supporting airway and resuscitation skill maintenance across neonatal units, particularly where skills are infrequently used.
Verbatim wording from the response “We acknowledge that, as care of the sickest neonates is concentrated in Level 3 units and the need for intubation is overall reduced, this can result in less opportunity for training and for maintaining skills. This goes well beyond a single procedural capability in the training curriculum for early years trainees, especially in an era of a multiprofessional workforce and increasing numbers of locally-employed doctor staff, especially at more junior levels.” Source location Response from RCPCH
Open published response
8 Nov 2024 Lacey May Brookman · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 6 Failure to reach a diagnosis in an ill patient View source Failure to recognise retrocaecal appendicitis as a presentation of acute appendicitis or generalised abdominal pain View source Inadequate training of doctors to consider appendicitis as a differential diagnosis for generalised abdominal pain View source Unavailability of bedside or departmental ultrasound scanning for abdominal pain View source Failure to consider appendicitis in patients with abdominal pain View source Failure to use bedside or departmental ultrasound scanning for abdominal pain View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Lacey May Brookman · 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
Lacey May Brookman, aged 11, experienced more than a week of abdominal pain and related symptoms before retrocaecal appendicitis was diagnosed after perforation and abscess formation. She underwent surgery and developed severe complications, including coagulopathy, disseminated intravascular coagulation and multiorgan failure, and died on 4 June 2021. Concerns included difficulty recognising retrocaecal appendicitis, and the availability and use of abdominal ultrasound scanning and training for doctors considering the diagnosis.
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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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Failure to reach a diagnosis in an ill patient
Wider context from the report “1. Neither the original GP, the reviewing surgical SHO or surgical registrar considered that Lacey had appendicitis. The Consultant surgeon reviewing Lacey on the 24th, considered she was ill but could not reach a diagnosis.
” 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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise retrocaecal appendicitis as a presentation of acute appendicitis or generalised abdominal pain
Wider context from the report “2. Despite the slant of available literature, it was evident retrocaecal appendicitis presentation is not a rare presentation of either acute appendicitis or generalised abdominal pain (both common presenting features in the young)
” 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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Inadequate training of doctors to consider appendicitis as a differential diagnosis for generalised abdominal pain
Wider context from the report “4. The training of doctors in considering the diagnosis as a possible differential to generalised abdominal pain.
” 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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Unavailability of bedside or departmental ultrasound scanning for abdominal pain
Wider context from the report “3. The availability and use of bedside/ departmental ultrasound scanning in abdominal pain (e.g. in the young) at any time, but especially out of hours
” 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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Failure to consider appendicitis in patients with abdominal pain
Wider context from the report “1. Neither the original GP, the reviewing surgical SHO or surgical registrar considered that Lacey had appendicitis. The Consultant surgeon reviewing Lacey on the 24th, considered she was ill but could not reach a diagnosis.
” 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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Failure to use bedside or departmental ultrasound scanning for abdominal pain
Wider context from the report “3. The availability and use of bedside/ departmental ultrasound scanning in abdominal pain (e.g. in the young) at any time, but especially out of hours
” Open source report
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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 Signpost members to the Best Practice Pathway Resource for paediatric acute abdominal pain and appendicectomy.
Verbatim wording from the response “You have additionally noted the Best Practice Pathway Resource for paediatric acute abdominal pain and appendicectomy, which was published in June 2022 by Getting It Right First Time (GIRFT), which was developed with several College members. We will ensure we signpost to this accordingly.” Source location Response from Royal College of Paediatrics and Child Health
Open published response
20 Aug 2024 Hannah Enola Ayamo Jacobs · Prevention of Future Deaths report East London
View report summary
Concerns raised 5 Allergy plans failing to distinguish lip swelling as a potential anaphylaxis symptom View source Insufficient education of parents and patients on safe AAI use when in doubt View source Failure to recognise inability to swallow as a sign of anaphylaxis in dental settings View source Lack of sufficiently clear distinction between anaphylactic and mild reactions View source Unavailability of AAI stock in chemists for emergencies View source See 2 more concerns
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Hannah Enola Ayamo Jacobs · 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
Hannah Enola Ayamo Jacobs, aged 13, developed anaphylactic symptoms after being served a dairy hot chocolate despite her reported dairy allergy and later died following cardiac arrest. The concerns included dental staff not recognising excessive salivation as inability to swallow and a sign of anaphylaxis, possible misunderstanding of symptoms by her mother, and the availability and use of adrenaline auto-injectors during shortages.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Allergy plans failing to distinguish lip swelling as a potential anaphylaxis symptom
Wider context from the report “• The other symptom Hannah demonstrated was swelling of her lips which is listed on allergy plans as a mild to moderate symptom and thus provided a false sense of reassurance to her mother that cetirizine was what she needed.
” 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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Insufficient education of parents and patients on safe AAI use when in doubt
Wider context from the report “• The risk of future deaths in the context of anaphylaxis remains in the absence of further consideration of what constitutes an anaphylactic reaction as opposed to a mild reaction, and the education of parents and patients of the safety of using AAIs (adrenaline auto injectors) IF IN DOUBT .
” 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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise inability to swallow as a sign of anaphylaxis in dental settings
Wider context from the report “• The evidence at the inquest referred to allergy action plans discussed in the healthcare settings and given to parents and patients. Hannah displayed what appeared to be excessive salivation at the dentist which her paediatric consultant (who gave evidence) said, with the benefit of hindsight was actually a manifestation of her inability to swallow. This is a sign of anaphylaxis This was not recognised by dental staff as an inability to swallow and thus of anaphylaxis.
” 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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Lack of sufficiently clear distinction between anaphylactic and mild reactions
Wider context from the report “• The risk of future deaths in the context of anaphylaxis remains in the absence of further consideration of what constitutes an anaphylactic reaction as opposed to a mild reaction , and the education of parents and patients of the safety of using AAIs (adrenaline auto injectors) IF IN DOUBT.
” 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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Unavailability of AAI stock in chemists for emergencies
Wider context from the report “• I was made aware there had been a shortage of AAI at the time but a vial of adrenaline was available at the chemist. However, it takes time to draw up. I am not sure if (assuming no national shortage) all chemists have AAI in stock for emergencies .
” Open source report
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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 Continue widely promoting Paediatric Allergy Training study days across the child health workforce.
Verbatim wording from the response “As the Royal College of Paediatrics and Child Health, we are primarily responsible for the education and training of paediatricians across the UK. We are not involved in the training of dentists and dental staff and have no role in the supply of epi-pens to pharmacies. As part of our training, we run CPD courses on child health topics that are of interest and relevance to the wider child health workforce. This includes Paediatric Allergy Training study days that focus on the practical clinical management of allergy in children and young people. These courses are suitable for all professionals seeing children with allergic disease. You can read more about these courses on our RCPCH Learning platform. We will ensure these continue to be widely promoted across the child health workforce.” Source location 2024-0464 Response from Royal College of Paediatrics
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Training dentists and dental staff, and supplying adrenaline auto-injectors to pharmacies, fall outside the organisation’s role.
Verbatim wording from the response “As the Royal College of Paediatrics and Child Health, we are primarily responsible for the education and training of paediatricians across the UK. We are not involved in the training of dentists and dental staff and have no role in the supply of epi-pens to pharmacies. As part of our training, we run CPD courses on child health topics that are of interest and relevance to the wider child health workforce. This includes Paediatric Allergy Training study days that focus on the practical clinical management of allergy in children and young people. These courses are suitable for all professionals seeing children with allergic disease. You can read more about these courses on our RCPCH Learning platform. We will ensure these continue to be widely promoted across the child health workforce.” Source location 2024-0464 Response from Royal College of Paediatrics
Open published response
Concerns raised 2 Failure to explicitly emphasise prompt escalation when observations cannot be obtained View source Emergency department electronic patient records failing to show repeat presentations during the current illness View source
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AI-generated summary
Daniel KLOSI · 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
Daniel died on his fourth presentation in a week to the Royal Free Hospital, with group A streptococcus sepsis recorded as the medical cause of death. Concerns included the delay in obtaining a full set of observations when he was distressed, and electronic records not showing how many times a patient had attended hospital with the same signs and symptoms during the current illness.
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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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Failure to explicitly emphasise prompt escalation when observations cannot be obtained
Wider context from the report “1. It was difficult for the nursing staff to obtain Daniel’s observations because he was so distressed. That was understandable, but because of the long wait in a busy department, it meant that on the fourth attendance Daniel did not have a full set of observations for over four hours and shortly afterwards suffered a catastrophic cardiovascular compromise.
I heard that obtaining no observations should be regarded in the same light as obtaining worrying observations, and should be escalated without delay .
It seems that this has not been emphasised explicitly to nursing and medical staff at the trust – and obviously may not have been in other trusts.
” 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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Emergency department electronic patient records failing to show repeat presentations during the current illness
Wider context from the report “2. The trust emergency department electronic patient records do not show how many times a patient has presented to hospital with the same signs and symptoms during their current illness – and of course this may be the case in other emergency departments.
” Open source report
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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 Collaborate with NHS England and the Royal College of Nursing to develop a single national Paediatric Early Warning System for England.
Verbatim wording from the response “As a college we are committed to the introduction, embedding and appropriate standardisation of Paediatric Early Warning Systems (PEWS) within the four nations. PEWS are designed to effectively recognise and respond to the deterioration of children or young people in a healthcare environment. A parental escalation process is essential to any effectively PEWS. We have been collaborating with NHS England and the Royal College of Nursing to develop a single national PEWS for England since 2018 and are supportive of equivalent processes across the UK.” Source location Response from RCPCH
Open published response
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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 Introduce, embed and standardise Paediatric Early Warning Systems across the four nations.
Verbatim wording from the response “As a college we are committed to the introduction, embedding and appropriate standardisation of Paediatric Early Warning Systems (PEWS) within the four nations. PEWS are designed to effectively recognise and respond to the deterioration of children or young people in a healthcare environment. A parental escalation process is essential to any effectively PEWS. We have been collaborating with NHS England and the Royal College of Nursing to develop a single national PEWS for England since 2018 and are supportive of equivalent processes across the UK.” Source location Response from RCPCH
Open published response
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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 Unobtainable observations should not automatically be treated like worrying observations because there are multiple reasons and assessment is holistic.
Verbatim wording from the response “1. I heard that obtaining no observations should be regarded in the same light as obtaining worrying observations and should be escalated without delay.” Source location Response from RCPCH
Open published response
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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 Responsibility for electronic patient records lies with the NHS, rather than the College.
Verbatim wording from the response “2. The trust emergency department electronic patient records do not show how many times a patient has presented to hospital with the same signs and symptoms during their current illness” Source location Response from RCPCH
Open published response
Concerns raised 3 Lack of child-applicable guidance for diagnosis and management of venous thromboembolic diseases View source Insufficient access to diagnostic and treatment resources for childhood thromboembolism View source Lack of validated child-specific screening tools for pulmonary thromboembolism View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
LILLY GRACE PROCTOR · 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
Lilly Proctor, aged 13, collapsed at home in the early hours of 3 April 2022 and died later that day in Pinderfields Hospital from massive pulmonary thromboembolism associated with deep vein thrombosis and hereditary Protein S deficiency. The report raises concerns that there was no child-specific UK screening tool or corresponding NICE guidance for venous thromboembolic disease in children, potentially disadvantaging clinicians diagnosing and treating the 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. The report was sent to Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Lack of child-applicable guidance for diagnosis and management of venous thromboembolic diseases
Wider context from the report “(2) NICE Guidance NG158 “Venous thromboembolic diseases: diagnosis, management and thrombophilia testing” is specific to adults. There is no corresponding guidance applicable to children . Similarly, the NICE Clinical Knowledge Summary for pulmonary embolism dated September 2023 is specific to adults with no corresponding publication applicable to children .
” 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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Insufficient access to diagnostic and treatment resources for childhood thromboembolism
Wider context from the report “(3) The rarity of thromboembolism in children gives rise to a concern that without access to resources similar to those available when dealing with the adult population, clinicians working with children may be disadvantaged in diagnosing and treating the condition , to the obvious potential detriment of their patients.
” 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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Lack of validated child-specific screening tools for pulmonary thromboembolism
Wider context from the report “(1) Whereas there are screening tools (such as “the Wells criteria”) to assist the detection of pulmonary thromboembolism in adults, no child-specific screening tool is available in the UK and no existing screening tool for use in the adult population has been validated for use in children in the UK . The inquest heard evidence of such child-specific screening tools being developed in other countries, of which Italy was an example.
” Open source report
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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 should take the lead in developing paediatric pulmonary thromboembolism screening tools and specific national guidance.
Verbatim wording from the response “Paediatricians and other clinicians who see unwell children and young people could benefit from an effective tool to assist the clinical detection of pulmonary thromboembolism in children and young people. Also a national guideline on this topic that is specific to children could be helpful. We would look to the National Institute for Healthcare Excellence to take a lead on this work to help develop a further evidence base or consensus guidance in this complex area of clinical practice. If this is to be taken forward, the College would be happy to assist and provide clinical expertise.” Source location Response from RCPCH
Open published response
Concerns raised 1 Lack of national guidance for investigating children with persistent symptoms after suspected ingestion of a non radio opaque object despite negative x-ray and fluoroscopy View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Kazarie T’Calla Kwaku DWAAH-LYDER · 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
Kazarie died after swallowing a googly eye in February 2022; the foreign body was not detected by x-ray or fluoroscopy, and he later became critically ill and was admitted to hospital in April 2023. The report raised concern about the lack of national guidance on investigating suspected swallowed non-radio-opaque foreign bodies when symptoms persist despite negative x-ray and fluoroscopy.
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. The report was sent to Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance for investigating children with persistent symptoms after suspected ingestion of a non radio opaque object despite negative x-ray and fluoroscopy
Wider context from the report “It was suggested to me in evidence that children suspected of having swallowed a non radio opaque object such as a googly eye, whose symptoms (unlike Kazarie’s) persist, should undergo an endoscopy even if they have had a negative x-ray and fluoroscopy.
I was told that there is a lack of national guidance for such a situation. I appreciate that there are multiple considerations in planning investigations, such as the risks associated with CT scanning and the risks associated with the administration of a general anaesthetic. It seems that the matter would benefit from consideration at a national level.
” Open source report
18 Dec 2023 Nuel-Junior DZERNJO · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 1 Lack of clear guidance on the appropriate route of Acyclovir treatment View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Nuel-Junior DZERNJO · 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
Nuel-Junior Dzernjo, who was receiving high-dose steroids and was immunosuppressed, developed chicken pox and deteriorated after being assessed at hospital on 21 February 2023. He was discharged despite ongoing abnormal observations, inability to mobilise and confusion, then deteriorated at home and died after collapsing the following day. The investigation identified unclear guidance on treatment, including whether intravenous rather than oral Acyclovir was indicated.
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. The report was sent to Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Lack of clear guidance on the appropriate route of Acyclovir treatment
Wider context from the report “During the course of my investigation into the death of Nuel-Junior I instructed an independent paediatric expert to review his management and opine on causation. During the course of hearing the evidence from the expert and all of the treating clinicians it became clear that there was some potentially relevant guidance available but it lacked clarity . Here intravenous Acyclovir, if prescribed, may have prevented Nuel-Junior's death but he was instead prescribed oral Acyclovir which was unlikely to have made a difference . Had clear guidance been available then Nuel-Junior's death may have been prevented.
” 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 Share report-derived information and local improvement suggestions with paediatric members through the patient safety portal, including promoting BNFC guidance.
Verbatim wording from the response “The College will be sharing information and suggestions for local improvement from your report with our paediatric members via its patient safety portal, including the promotion of the BNFC guidance to improve awareness across the profession. The information within your report will also be shared for discussion with the RCPCH Clinical Quality in Practice group in early Spring, where further actions may be identified.” Source location Response from Royal College of Paediatrics and Child health
Open published response
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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 BNFC guidance for intravenous treatment of varicella in immunocompromised children is clear, contrary to the concern that guidance was unclear.
Verbatim wording from the response “Thank you for sharing your report with us regarding the tragic and untimely passing of Nuel-Junior. We were saddened to read the circumstances surrounding Nuel-Junior’s death and have discussed with senior colleagues within the RCPCH and the British Paediatric Allergy, Immunity and Infection Group (BPAIIG). Thank you for confirming in a separate correspondence that the doctors knew that Nuel-Junior was immunocompromised, and that he was initially not particularly "unwell" and presented with typical signs of chickenpox (including a temperature and spots/lesions). You described further that Dr Louis Grandjean, an independent paediatric expert instructed by the court, was of the view that the guidance was unclear.” Source location Response from Royal College of Paediatrics and Child health
Open published response
Concerns raised 3 Reduction in paediatric middle grades' practical experience in neonatal resuscitation View source Lower level of consultant general paediatricians' experience in complex neonatal resuscitation View source Reliance on consultants who may be non-resident on call during neonatal resuscitation View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Luca Yates · 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
Luca Yates was born by emergency caesarean section on 23 January 2022 after fetal bradycardia was detected, and died the following day after difficult resuscitation. The inquest found that he died from complications of asphyxia around the time of birth, with concerns including failure to recognise established or transitioning labour, absence of hospital monitoring, and non-use of 100% oxygen during part of resuscitation. The report also raised concerns about future paediatric doctors having reduced experience in neonatal resuscitation.
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. The report was sent to Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Reduction in paediatric middle grades' practical experience in neonatal resuscitation
Wider context from the report “The court heard evidence as to planned changes to paediatric specialist training which will result in a reduction in amount of time specialty trainees are required to spend gaining experience in Level 3 Neonatal units .
The following matters of concern arise from this:-
1) It is a matter of concern that paediatric middle grades may have reduced practical experience in resuscitation of neonates born in poor condition , that will increase the reliance on Consultants (who in some clinical settings may be non-resident on call depending when delivery takes place); and
2) It is a matter of concern that Consultant general paediatricians of the future will have a lower level of experience than is currently the case of complex neonatal resuscitation.
” 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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Lower level of consultant general paediatricians' experience in complex neonatal resuscitation
Wider context from the report “The court heard evidence as to planned changes to paediatric specialist training which will result in a reduction in amount of time specialty trainees are required to spend gaining experience in Level 3 Neonatal units.
The following matters of concern arise from this:-
1) It is a matter of concern that paediatric middle grades may have reduced practical experience in resuscitation of neonates born in poor condition, that will increase the reliance on Consultants (who in some clinical settings may be non-resident on call depending when delivery takes place); and
2) It is a matter of concern that Consultant general paediatricians of the future will have a lower level of experience than is currently the case of complex neonatal resuscitation .
” 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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Reliance on consultants who may be non-resident on call during neonatal resuscitation
Wider context from the report “The court heard evidence as to planned changes to paediatric specialist training which will result in a reduction in amount of time specialty trainees are required to spend gaining experience in Level 3 Neonatal units.
The following matters of concern arise from this:-
1) It is a matter of concern that paediatric middle grades may have reduced practical experience in resuscitation of neonates born in poor condition, that will increase the reliance on Consultants (who in some clinical settings may be non-resident on call depending when delivery takes place) ; and
2) It is a matter of concern that Consultant general paediatricians of the future will have a lower level of experience than is currently the case of complex neonatal resuscitation.
” 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 Require general paediatric specialty trainees to spend time in a neonatal setting.
Verbatim wording from the response “E. General paediatric consultants experience of neonatal resuscitation” Source location Response from Royal College of Paediatrics and Child Health
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 Require all core trainees to spend time in a neonatal setting during training.
Verbatim wording from the response “It is true that there are no specific mandatory placements during core training. This is because the curricular learning outcomes and key capabilities are generic in nature and can be acquired in most settings. However, in order to meet the key capabilities related to neonatal care (see below) and to prepare trainees to be on tier 2 rotas at ST4 covering neonatal units, all trainees will spend time during their core training in a neonatal setting. Full” Source location Response from Royal College of Paediatrics and Child Health
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 Use a formal supervisor assessment to confirm trainee readiness for tier 2 rota work.
Verbatim wording from the response “The capabilities to lead neonatal resuscitation will be largely acquired and maintained through training and simulation, augmented by clinical experience. The key capabilities needed are outlined in the core syllabus document and are clearly aligned to the need for neonatal resuscitation skills. It is our view that these key capabilities, combined with our new 'readiness for tier 2 working' assessment form, and the much more specific (and safe) airway capabilities in the core curriculum do provide safe training to manage neonatal resuscitation as the first senior responder – always with consultant support available to come in from home. In addition, there continues to be a requirement to be a current Newborn Life Support (NLS) provider in order to work on the tier 2 rota.” Source location Response from Royal College of Paediatrics and Child Health
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 Maintain mandatory specialty-level capabilities for neonatal resuscitation and airway management.
Verbatim wording from the response “70% of paediatric trainees will train as general paediatricians, of which a significant proportion will go on to work in a DGH covering a local neonatal unit or SCBU where there may be a need for neonatal resuscitation. In recognition of this, the general paediatric specialty level syllabus has mandatory key capabilities relating to neonatal resuscitation and airway management. To evidence these, trainees at specialty level following the general paediatric pathway will need to spend time in a neonatal setting again.” Source location Response from Royal College of Paediatrics and Child Health
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 Mandatory non-invasive airway skills, readiness assessment, consultant support and current Newborn Life Support status provide safe preparation for neonatal resuscitation.
Verbatim wording from the response “The capabilities to lead neonatal resuscitation will be largely acquired and maintained through training and simulation, augmented by clinical experience. The key capabilities needed are outlined in the core syllabus document and are clearly aligned to the need for neonatal resuscitation skills. It is our view that these key capabilities, combined with our new 'readiness for tier 2 working' assessment form, and the much more specific (and safe) airway capabilities in the core curriculum do provide safe training to manage neonatal resuscitation as the first senior responder – always with consultant support available to come in from home. In addition, there continues to be a requirement to be a current Newborn Life Support (NLS) provider in order to work on the tier 2 rota.” Source location Response from Royal College of Paediatrics and Child Health
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 Specific mandatory neonatal placements are unnecessary because capabilities can be acquired in most settings, with all trainees spending time in a neonatal setting.
Verbatim wording from the response “It is true that there are no specific mandatory placements during core training. This is because the curricular learning outcomes and key capabilities are generic in nature and can be acquired in most settings. However, in order to meet the key capabilities related to neonatal care (see below) and to prepare trainees to be on tier 2 rotas at ST4 covering neonatal units, all trainees will spend time during their core training in a neonatal setting. Full” Source location Response from Royal College of Paediatrics and Child Health
Open published response
16 Sep 2023 Sienna Scarlett Monterio · Prevention of Future Deaths report Blackpool and the Fylde
View report summary
Concerns raised 2 Failure to make haemoglobin analysis available in neonatal resuscitation cord blood gas testing View source Lack of national regulation and Newborn Life Support process inclusion for cord blood testing View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Sienna Scarlett Monterio · 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
Sienna Scarlett Monterio was born by emergency caesarean section on 6 April 2022 and died later that morning following a severe fetal-maternal haemorrhage. The report raises concern that blood gas analysers may not be configured to measure haemoglobin in neonatal resuscitation settings, with variation between trusts potentially limiting information available to clinicians; it states this issue did not contribute to Sienna’s death.
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. The report was sent to Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Failure to make haemoglobin analysis available in neonatal resuscitation cord blood gas testing
Wider context from the report “Having reviewed the circumstances surrounding Sienna’s death, the Healthcare Safety Investigation Branch [HSIB] found that at the time of birth the blood gas analyser was not set to analyse the haemoglobin .
The HSIB very clearly state that in the absence of this data , this “prevented other possible causes for the Baby’s condition being considered and possibly corrected.”
The HSIB has also recommended this facility is available in all neonatal resuscitation settings to support the provision of clinical information, and to optimise decision making processes and clinical care.
Sienna was born following an urgent caesarean section, and died within two hours of delivery. Those who work in this area inevitably have to make urgent, life-saving decisions and in the most challenging of circumstances, and it seems to me that there is a lack of clarity on this issue which needs to be addressed. In the absence of such clarity, a baby may die from a preventable cause which is not appreciated by clinicians in the absence of data which would have highlighted a low haemoglobin level in the blood cord gas .
It appears that in some trusts, this data will be readily available, but not in others. If ████████ comment above is correct, there may be different practices within the one trust.
The court has been told that cord blood testing is not regulated or included in the Newborn Life Support (NLS) process at a national level. It appears as though the hospital trust in Blackpool is considering this issue appropriately, and this may reflect the picture nationally.
The HSIB states this data may assist in identifying other possible causes for a baby’s condition being considered, and possibly corrected. ████████ expresses the view that he sees no potential disadvantage in having the Hb measurement being readily available in the cord blood gas from a clinical perspective. I have therefore concluded that there is risk of future deaths and that I therefore have a duty to write this report.
” 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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Lack of national regulation and Newborn Life Support process inclusion for cord blood testing
Wider context from the report “Having reviewed the circumstances surrounding Sienna’s death, the Healthcare Safety Investigation Branch [HSIB] found that at the time of birth the blood gas analyser was not set to analyse the haemoglobin.
The HSIB very clearly state that in the absence of this data, this “prevented other possible causes for the Baby’s condition being considered and possibly corrected.”
The HSIB has also recommended this facility is available in all neonatal resuscitation settings to support the provision of clinical information, and to optimise decision making processes and clinical care.
Sienna was born following an urgent caesarean section, and died within two hours of delivery. Those who work in this area inevitably have to make urgent, life-saving decisions and in the most challenging of circumstances, and it seems to me that there is a lack of clarity on this issue which needs to be addressed . In the absence of such clarity, a baby may die from a preventable cause which is not appreciated by clinicians in the absence of data which would have highlighted a low haemoglobin level in the blood cord gas.
It appears that in some trusts, this data will be readily available, but not in others . If ████████ comment above is correct, there may be different practices within the one trust .
The court has been told that cord blood testing is not regulated or included in the Newborn Life Support (NLS) process at a national level . It appears as though the hospital trust in Blackpool is considering this issue appropriately, and this may reflect the picture nationally.
The HSIB states this data may assist in identifying other possible causes for a baby’s condition being considered, and possibly corrected. ████████ expresses the view that he sees no potential disadvantage in having the Hb measurement being readily available in the cord blood gas from a clinical perspective. I have therefore concluded that there is risk of future deaths and that I therefore have a duty to write this report.
” Open source report
Concerns raised 2 Failure to provide clear and consistent guidance when applying the Kaiser Permanente Score and NICE guidance View source Failure to use the Kaiser Permanente Score as part of an overall assessment of the patient View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Baby Isabela Suciu · 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
Baby Isabela Suciu was born in hospital and later suffered a cardiac arrest at home after feeding; she did not regain consciousness and died in hospital. Concerns included the failure to escalate low temperatures for paediatric review or start antibiotics, amid conflicting Kaiser Permanente and NICE guidance. The report identified a continuing risk of confusion and avoidable delay in other neonatal units, although the omission was not shown to have caused Isabela’s death.
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. The report was sent to Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Failure to provide clear and consistent guidance when applying the Kaiser Permanente Score and NICE guidance
Wider context from the report “If the Newborn Early Warning Trigger and Track score had been followed the hypothermia would have triggered escalation by the midwife to paediatricians at 02.00 when the temperature was 36.3. Paediatrician ████████, advised that the KP score would not alter then, but at 06.20, the temperature of 36.2 should have triggered starting antibiotics. There was agreement amongst experts that antibiotics should have been started at 06.20 on 3rd of November. It is accepted by the doctors and Trust that this should have happened and did not because of conflict between the Kaiser Permanente Score and the NICE guidance. Whilst this omission was not shown to have caused Isabela’s death, it creates a possible risk for other hospitals using the KP scale.
Expert microbiologist ███████████ informed the court that it was not that the KP scale was inferior to NICE recommendations, but rather that there is a risk as the threshold for antibiotics is different, that doctors will think the KP score is gospel and not look at the patient as a whole and therefore miss clinical signs which should trigger starting antibiotics.
████████████████, consultant neonatology expert opined that the evidence for the use of KP pathway was thin, and it was better to follow NICE guidance as KP should only be used as part of an overall assessment. Expert neonatologist █████████████ agreed saying that the use of two guidelines was confusing .
████████ expert opinion was that there was a risk of deaths in other neonatal units and that the expert was not sure how well known the differences and apparent conflict in applying the guidelines was known. The Trust have taken a number of steps to address the risk, but there appears to remain the opportunity for confusion as the revised Newborn Early Warning Trigger and Track score indicates a different response from KP, when late onset symptoms occur after an asymptomatic period, creating a risk of avoidable delay .
” 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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Failure to use the Kaiser Permanente Score as part of an overall assessment of the patient
Wider context from the report “If the Newborn Early Warning Trigger and Track score had been followed the hypothermia would have triggered escalation by the midwife to paediatricians at 02.00 when the temperature was 36.3. Paediatrician ████████, advised that the KP score would not alter then, but at 06.20, the temperature of 36.2 should have triggered starting antibiotics. There was agreement amongst experts that antibiotics should have been started at 06.20 on 3rd of November. It is accepted by the doctors and Trust that this should have happened and did not because of conflict between the Kaiser Permanente Score and the NICE guidance. Whilst this omission was not shown to have caused Isabela’s death, it creates a possible risk for other hospitals using the KP scale.
Expert microbiologist ███████████ informed the court that it was not that the KP scale was inferior to NICE recommendations, but rather that there is a risk as the threshold for antibiotics is different, that doctors will think the KP score is gospel and not look at the patient as a whole and therefore miss clinical signs which should trigger starting antibiotics.
████████████████, consultant neonatology expert opined that the evidence for the use of KP pathway was thin, and it was better to follow NICE guidance as KP should only be used as part of an overall assessment . Expert neonatologist █████████████ agreed saying that the use of two guidelines was confusing.
████████ expert opinion was that there was a risk of deaths in other neonatal units and that the expert was not sure how well known the differences and apparent conflict in applying the guidelines was known. The Trust have taken a number of steps to address the risk, but there appears to remain the opportunity for confusion as the revised Newborn Early Warning Trigger and Track score indicates a different response from KP, when late onset symptoms occur after an asymptomatic period, creating a risk of avoidable delay.
” Open source report
Concerns raised 2 Lack of NICE guidance for diagnosing and treating Group A Streptococcus in high-risk groups View source Failure to consider rapid antigen testing for Group A Streptococcus in children under 5 View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Sienna Daisy Barber · 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
Sienna Daisy Barber, a previously healthy child, developed a high temperature and was assessed by her GP, NHS 111 and at hospital before becoming increasingly unwell and dying at Royal Oldham Hospital on 29 January 2022. The report raised concerns about the absence of NICE guidance for diagnosing and treating Group A Streptococcus, particularly for high-risk groups including children under five, and about the lack of recommended rapid antigen testing for this group.
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. The report was sent to Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Lack of NICE guidance for diagnosing and treating Group A Streptococcus in high-risk groups
Wider context from the report “1. The court heard evidence that since 2014 cases of Group A Streptococcus have increased annually. After Sienna’s death in December 2022 there was a significant increase of cases in young children.
Whilst emergency guidance was issued to practitioners in December 2022 this related to the threshold for the administration of treatment in cases where Group A Streptococcus. This guidance has itself now been withdrawn. The court heard that unlike other conditions such as Meningitis there is no NICE guidance for practitioners to assist them with how to diagnose / treat Group A Streptococcus. Apparently there has been previous consideration of this but a decision was taken not to provide such guidance. The court was advised this decision was taken having considered the impact of Group A Streptococcus on the whole of the population. However the court informed that there are three high risk groups, these being ; i) Children under the age of 5, ii) women who have given birth in the last month and iii) the over 75’s.
In my opinion consideration of guidance targeted towards these three high risk groups should be considered.
” 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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Failure to consider rapid antigen testing for Group A Streptococcus in children under 5
Wider context from the report “2. The court also heard that in 2019 a NICE publication considering rapid antigen testing was published. This did not recommend rapid antigen testing. However this publication excluded consideration of testing in the high risk group, the under 5’s. Rapid antigen testing is carried out in other countries such as the USA and Canada. The court heard Sienna would have been entirely the sort of patient where such testing would have been appropriate on the 25th January 2022 when she was examined at North Manchester and she would have immediately been commenced on the treatment for Group A streptococcus, penicillin.
In my opinion consideration should be given for rapid antigen testing in the under 5’s in such cases.
” Open source report
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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 Endorse the reinstatement of NICE sore-throat guidance following clinical risk-benefit review.
Verbatim wording from the response “It was the case that interim guidance was withdrawn following the spike in Group A Streptococcus in December 2022, and replaced by the reinstatement of the NICE Sore Throat (Acute) NG84 guideline for all age groups¹.” Source location Response from Royal College of Paediatrics and Child Health
Open published response
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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 Existing NICE fever guidance is viewed as robust and supports appropriate antibiotic decisions for children under five.
Verbatim wording from the response “It was the case that interim guidance was withdrawn following the spike in Group A Streptococcus in December 2022, and replaced by the reinstatement of the NICE Sore Throat (Acute) NG84 guideline for all age groups¹.” Source location Response from Royal College of Paediatrics and Child Health
Open published response
28 Mar 2023 Louis James Rogers · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 10 Failure to document general practice assessment of febrile seizures View source Failure to make timely referrals from general practice to secondary medical services for febrile seizures View source Sudden unexpected death in childhood following febrile seizures View source Failure to make paramedic information available to all clinicians View source Lack of coordinated response across clinicians to febrile seizure presentations View source Delays in referral for assessment and investigation of febrile seizures View source Failure to ensure febrile seizure diagnoses are supported by the child’s presentation View source Failure to undertake a detailed history and full neurological examination in general practice View source Failure to follow escalation guidance for complex febrile seizures View source Insufficient information for parents and guardians after a child’s febrile seizure View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Louis James Rogers · 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
Louis James Rogers died after being found unresponsive at home following a period of clinical illness and was pronounced dead on 18 June 2021 despite resuscitation attempts. Autopsy identified a viral infection, and genetic studies confirmed Dravet’s Syndrome. The report raised concerns about the management and investigation of febrile seizures, information provided to parents, paramedic and general practice guidance, and the lack of a coordinated febrile seizure pathway.
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. The report was sent to Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Failure to document general practice assessment of febrile seizures
Wider context from the report “4. General Practice -
At his mother’s request after the possibility of a further seizure, Louis was reviewed by his general practitioner on the 13th May 2021 following which Louis’s mother was reassured without a detailed history from Louis’s mother or a full neurological examination and in the absence of documentation in circumstances whereby it was acknowledged there was sufficient information at that time to refer Louis to secondary services for the management of children with febrile seizures. It would therefore be appropriate to consider providing robust national guidance and education to general practitioners to ensure appropriate history, examination, investigation are undertaken to allow timely referrals to secondary medical services to be undertaken.
” 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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Failure to make timely referrals from general practice to secondary medical services for febrile seizures
Wider context from the report “4. General Practice -
At his mother’s request after the possibility of a further seizure, Louis was reviewed by his general practitioner on the 13th May 2021 following which Louis’s mother was reassured without a detailed history from Louis’s mother or a full neurological examination and in the absence of documentation in circumstances whereby it was acknowledged there was sufficient information at that time to refer Louis to secondary services for the management of children with febrile seizures. It would therefore be appropriate to consider providing robust national guidance and education to general practitioners to ensure appropriate history, examination, investigation are undertaken to allow timely referrals to secondary medical services to be undertaken .
” 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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Sudden unexpected death in childhood following febrile seizures
Wider context from the report “1. Management and investigation of Febrile Seizures
Evidence was heard that a number of children who have ‘febrile’ seizures subsequently die from ‘sudden unexpected death in childhood’ . Evidence was provided that there should be greater emphasis on medical education, research and public information for sudden unexpected deaths associated with febrile seizures. Further evidence was heard that referrals for assessment and investigation of febrile seizures should be undertaken earlier to exclude a more severe underlying illness.
” 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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Failure to make paramedic information available to all clinicians
Wider context from the report “5. Febrile Seizure Pathway
Evidence was heard that Louis was seen by a number of clinicians without a co-ordinated response to his presentation and that consideration should be given for all hospitals emergency departments and GP’s to be provided with a febrile seizure pathway as a checklist to ensure children are not given a diagnosis of a ‘febrile seizure when this is not supported by their presentation and for all consultations – including GP appointment and information from the paramedics is available for all clinicians to view to provide a holistic picture and to assist further management.
” 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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Lack of coordinated response across clinicians to febrile seizure presentations
Wider context from the report “5. Febrile Seizure Pathway
Evidence was heard that Louis was seen by a number of clinicians without a co-ordinated response to his presentation and that consideration should be given for all hospitals emergency departments and GP’s to be provided with a febrile seizure pathway as a checklist to ensure children are not given a diagnosis of a ‘febrile seizure when this is not supported by their presentation and for all consultations – including GP appointment and information from the paramedics is available for all clinicians to view to provide a holistic picture and to assist further management.
” 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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Delays in referral for assessment and investigation of febrile seizures
Wider context from the report “1. Management and investigation of Febrile Seizures
Evidence was heard that a number of children who have ‘febrile’ seizures subsequently die from ‘sudden unexpected death in childhood’. Evidence was provided that there should be greater emphasis on medical education, research and public information for sudden unexpected deaths associated with febrile seizures. Further evidence was heard that referrals for assessment and investigation of febrile seizures should be undertaken earlier to exclude a more severe underlying illness.
” 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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure febrile seizure diagnoses are supported by the child’s presentation
Wider context from the report “5. Febrile Seizure Pathway
Evidence was heard that Louis was seen by a number of clinicians without a co-ordinated response to his presentation and that consideration should be given for all hospitals emergency departments and GP’s to be provided with a febrile seizure pathway as a checklist to ensure children are not given a diagnosis of a ‘febrile seizure when this is not supported by their presentation and for all consultations – including GP appointment and information from the paramedics is available for all clinicians to view to provide a holistic picture and to assist further management.
” 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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake a detailed history and full neurological examination in general practice
Wider context from the report “4. General Practice -
At his mother’s request after the possibility of a further seizure, Louis was reviewed by his general practitioner on the 13th May 2021 following which Louis’s mother was reassured without a detailed history from Louis’s mother or a full neurological examination and in the absence of documentation in circumstances whereby it was acknowledged there was sufficient information at that time to refer Louis to secondary services for the management of children with febrile seizures. It would therefore be appropriate to consider providing robust national guidance and education to general practitioners to ensure appropriate history, examination, investigation are undertaken to allow timely referrals to secondary medical services to be undertaken.
” 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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Failure to follow escalation guidance for complex febrile seizures
Wider context from the report “3. Improvement to and highlighting of the JRCALC guidelines for paramedic management of seizures in children
JRCALC guidelines indicated paramedics should have conveyed Louis to hospital or contacted the GP and/or Out of Hours GP service following Louis’s second seizure on 11th February 2020, as the close proximity of two seizures indicated it was a ‘complex febrile seizure’ rather than a febrile seizure. This led to a lost opportunity to expeditiously trigger further investigation and/or a referral to either the ‘first seizure’ service or to a specialist paediatrician for further assessment and management. Evidence was heard that improving and highlighting JRCALC guidelines with additional teaching would prevent this happening again.
” 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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Insufficient information for parents and guardians after a child’s febrile seizure
Wider context from the report “2. Information provided to parents/guardians after their child had a Febrile Seizure
Evidence was heard that the NHS website and pamphlet provided to parents/guardians following a child’s febrile seizure is insufficiently informative to provide parents with sufficiently detailed information to assist them in picking up potential early indicators of a more severe illness e.g. issues with gait, co-ordination, definition of complex seizures, developmental regression etc.
” Open source report
11 Aug 2022 Lily May Girton · Prevention of Future Deaths report East London
View report summary
Concerns raised 2 Lack of adequate numbers of suitably trained CAMHS staff View source Excessive consultant caseloads in CAMHS View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Lily May Girton · 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
Lily May Girton, who had anxiety, depression and emotional dysregulation, died after taking her own life while suffering from mental illness. The inquest found that her death was contributed to by failures in the community CAMHS team concerning psychiatric assessment, risk management and titration of antidepressant medication. It also raised concerns that inadequate staffing and resources in CAMHS services pose a risk of future deaths of young people.
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. The report was sent to Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Lack of adequate numbers of suitably trained CAMHS staff
Wider context from the report “The Inquest heard that CAMHS services nationally have a lack of adequate staffing levels in the form of doctors, in the form of psychiatrists, registered mental health nurses and psychotherapy staff . The Inquest heard that consultants often have an average of 130 to 150 active cases on their caseloads. This is substantially higher than the recommended caseloads by the Royal College of Psychiatrists.
The lack of staffing and resources contributed to Lily’s death and there is a concern that the ongoing shortages of suitably trained staff within CAMHS teams poses a risk of future deaths of young people .
” 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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Excessive consultant caseloads in CAMHS
Wider context from the report “The Inquest heard that CAMHS services nationally have a lack of adequate staffing levels in the form of doctors, in the form of psychiatrists, registered mental health nurses and psychotherapy staff. The Inquest heard that consultants often have an average of 130 to 150 active cases on their caseloads . This is substantially higher than the recommended caseloads by the Royal College of Psychiatrists .
The lack of staffing and resources contributed to Lily’s death and there is a concern that the ongoing shortages of suitably trained staff within CAMHS teams poses a risk of future deaths of young people.
” Open source report
Concerns raised 5 Failure to consider the timing of requests for advice in 111 dispositions View source Failure to accommodate prior direct general practitioner review in 111 dispositions View source Lack of detailed assessment of the degree of apparent concern View source Unavailability of accessible paediatric infrastructure in an out-of-hours GP service View source Failure to question the nature of vomitus in young children View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Esma GUZEL · 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
Esma Guzel, aged five, died on 10 May 2019 after developing vomiting and abdominal pain due to complications of a congenital diaphragmatic hernia. After a GP assessment and subsequent deterioration, the 111 service advised attendance at an out-of-hours GP service, where she arrived in cardiac arrest and could not be resuscitated. The principal concerns relate to questioning about vomitus, the 111 algorithm’s assessment and disposition, and referral to paediatric services.
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. The report was sent to Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Failure to consider the timing of requests for advice in 111 dispositions
Wider context from the report “I have presented with evidence prior to and at inquest, that diligent questioning as to the nature of vomitus in a five-year-old patient, would have alerted a competent practitioner to the requirement for urgent hospitalisation. The facts of this case are that with the child continuing to be unwell eight hours later, the 111 algorithm led to her being driven by her father to an out-of-hours GP run service with no accessible paediatric infrastructure, where she arrived in a state of cardiac arrest. The 111 algorithm has been subject to modification in the light of these events, but I remain concerned that there is no detailed assessment of the degree of apparent concern, no accommodation of the prior direct review by a general practitioner, and no consideration of the timing of the request for advice , when reaching a disposition that does not involve referral to paediatric services. It is difficult to reconcile professional opinion that this patient should have been referred to paediatric services on the basis of features at 5 PM but not in the small hours of the morning with a deterioration in her condition by that stage. I have heard in evidence that an educational message on ‘rare causes for common symptoms’ could be circulated as a case report, but take the view that the lead professional bodies for both general practice and child health should consider how such information is effectively disseminated, and whether the algorithms and dispositions generated by the 111 service need further modification to maximise the chance of expedited optimal care for what is acknowledged to be an uncommon condition. I have heard in evidence that the 111 service is the default safety net arrangement in such circumstances, and this therefore requires endorsement by your professional bodies, if it is to command the confidence of patients, parents and practitioners as a definitive safety net.
” 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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Failure to accommodate prior direct general practitioner review in 111 dispositions
Wider context from the report “I have presented with evidence prior to and at inquest, that diligent questioning as to the nature of vomitus in a five-year-old patient, would have alerted a competent practitioner to the requirement for urgent hospitalisation. The facts of this case are that with the child continuing to be unwell eight hours later, the 111 algorithm led to her being driven by her father to an out-of-hours GP run service with no accessible paediatric infrastructure, where she arrived in a state of cardiac arrest. The 111 algorithm has been subject to modification in the light of these events, but I remain concerned that there is no detailed assessment of the degree of apparent concern, no accommodation of the prior direct review by a general practitioner , and no consideration of the timing of the request for advice, when reaching a disposition that does not involve referral to paediatric services. It is difficult to reconcile professional opinion that this patient should have been referred to paediatric services on the basis of features at 5 PM but not in the small hours of the morning with a deterioration in her condition by that stage. I have heard in evidence that an educational message on ‘rare causes for common symptoms’ could be circulated as a case report, but take the view that the lead professional bodies for both general practice and child health should consider how such information is effectively disseminated, and whether the algorithms and dispositions generated by the 111 service need further modification to maximise the chance of expedited optimal care for what is acknowledged to be an uncommon condition. I have heard in evidence that the 111 service is the default safety net arrangement in such circumstances, and this therefore requires endorsement by your professional bodies, if it is to command the confidence of patients, parents and practitioners as a definitive safety net.
” 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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Lack of detailed assessment of the degree of apparent concern
Wider context from the report “I have presented with evidence prior to and at inquest, that diligent questioning as to the nature of vomitus in a five-year-old patient, would have alerted a competent practitioner to the requirement for urgent hospitalisation. The facts of this case are that with the child continuing to be unwell eight hours later, the 111 algorithm led to her being driven by her father to an out-of-hours GP run service with no accessible paediatric infrastructure, where she arrived in a state of cardiac arrest. The 111 algorithm has been subject to modification in the light of these events, but I remain concerned that there is no detailed assessment of the degree of apparent concern , no accommodation of the prior direct review by a general practitioner, and no consideration of the timing of the request for advice, when reaching a disposition that does not involve referral to paediatric services. It is difficult to reconcile professional opinion that this patient should have been referred to paediatric services on the basis of features at 5 PM but not in the small hours of the morning with a deterioration in her condition by that stage. I have heard in evidence that an educational message on ‘rare causes for common symptoms’ could be circulated as a case report, but take the view that the lead professional bodies for both general practice and child health should consider how such information is effectively disseminated, and whether the algorithms and dispositions generated by the 111 service need further modification to maximise the chance of expedited optimal care for what is acknowledged to be an uncommon condition. I have heard in evidence that the 111 service is the default safety net arrangement in such circumstances, and this therefore requires endorsement by your professional bodies, if it is to command the confidence of patients, parents and practitioners as a definitive safety net.
” 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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Unavailability of accessible paediatric infrastructure in an out-of-hours GP service
Wider context from the report “I have presented with evidence prior to and at inquest, that diligent questioning as to the nature of vomitus in a five-year-old patient, would have alerted a competent practitioner to the requirement for urgent hospitalisation. The facts of this case are that with the child continuing to be unwell eight hours later, the 111 algorithm led to her being driven by her father to an out-of-hours GP run service with no accessible paediatric infrastructure , where she arrived in a state of cardiac arrest. The 111 algorithm has been subject to modification in the light of these events, but I remain concerned that there is no detailed assessment of the degree of apparent concern, no accommodation of the prior direct review by a general practitioner, and no consideration of the timing of the request for advice, when reaching a disposition that does not involve referral to paediatric services. It is difficult to reconcile professional opinion that this patient should have been referred to paediatric services on the basis of features at 5 PM but not in the small hours of the morning with a deterioration in her condition by that stage. I have heard in evidence that an educational message on ‘rare causes for common symptoms’ could be circulated as a case report, but take the view that the lead professional bodies for both general practice and child health should consider how such information is effectively disseminated, and whether the algorithms and dispositions generated by the 111 service need further modification to maximise the chance of expedited optimal care for what is acknowledged to be an uncommon condition. I have heard in evidence that the 111 service is the default safety net arrangement in such circumstances, and this therefore requires endorsement by your professional bodies, if it is to command the confidence of patients, parents and practitioners as a definitive safety net.
” 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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Failure to question the nature of vomitus in young children
Wider context from the report “I have presented with evidence prior to and at inquest, that diligent questioning as to the nature of vomitus in a five-year-old patient, would have alerted a competent practitioner to the requirement for urgent hospitalisation . The facts of this case are that with the child continuing to be unwell eight hours later, the 111 algorithm led to her being driven by her father to an out-of-hours GP run service with no accessible paediatric infrastructure, where she arrived in a state of cardiac arrest. The 111 algorithm has been subject to modification in the light of these events, but I remain concerned that there is no detailed assessment of the degree of apparent concern, no accommodation of the prior direct review by a general practitioner, and no consideration of the timing of the request for advice, when reaching a disposition that does not involve referral to paediatric services. It is difficult to reconcile professional opinion that this patient should have been referred to paediatric services on the basis of features at 5 PM but not in the small hours of the morning with a deterioration in her condition by that stage. I have heard in evidence that an educational message on ‘rare causes for common symptoms’ could be circulated as a case report, but take the view that the lead professional bodies for both general practice and child health should consider how such information is effectively disseminated, and whether the algorithms and dispositions generated by the 111 service need further modification to maximise the chance of expedited optimal care for what is acknowledged to be an uncommon condition. I have heard in evidence that the 111 service is the default safety net arrangement in such circumstances, and this therefore requires endorsement by your professional bodies, if it is to command the confidence of patients, parents and practitioners as a definitive safety net.
” 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 develops and manages NHS 111 algorithms, so responsibility for their modification rests with NHS Digital.
Verbatim wording from the response “It was useful to hear about the change to the 111 algorithms as a result of learning from the circumstances surrounding Esma’s passing. The pathways used to inform 111 are currently developed and managed by NHS Digital to the NHS in England and to individual users, including but not limited to NHS Pathways and 111online.nhs.uk. The RCPCH are not required to and do not endorse these pathways but paediatricians represent the RCPCH to provide clinical advice and expertise to inform their shaping and to provide clinical expertise on ad hoc queries and patient safety concerns.” Source location Response from Royal College of Paediatrics and Child Health
Open published response
20 Apr 2021 Ella Adoo-Kissi-Debrah · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 6 Insufficient undergraduate teaching on the health effects of air pollution View source Insufficient postgraduate education on the health effects of air pollution View source Insufficient detail and monitoring capacity for air quality information View source Insufficient professional guidance on communicating the health effects of air pollution View source Low public awareness of sources of national and local pollution information View source National Particulate Matter limits exceeding WHO guideline levels View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ella Adoo-Kissi-Debrah · 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
Ella Adoo-Kissi-Debrah died aged 9 after an asthmatic episode led to cardiac arrest on 15 February 2013. The report states that air pollution, including exposure to nitrogen dioxide and particulate matter from traffic emissions, significantly contributed to her asthma and death. It also identifies concerns about pollution limits, public access to pollution information, and communication of air-pollution health risks by healthcare professionals.
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. The report was sent to Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Insufficient undergraduate teaching on the health effects of air pollution
Wider context from the report “(3) The adverse effects of air pollution on health are not being sufficiently communicated to patients and their carers by medical and nursing professionals. The evidence at the inquest was that this needs to be addressed at three levels:
a. Undergraduate. I am informed that undergraduate teaching is the responsibility of the GMC, Health Education England and the NMC.
b. Postgraduate. I am informed that postgraduate education is the responsibility of the Royal Colleges, in this case the Royal College of Physicians, the Royal College of Paediatrics and Child Health, the Royal College of General Practitioners, and the NMC.
c. Professional guidance. In this case relevant organisations are NICE and the British Thoracic Society.
” 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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Insufficient postgraduate education on the health effects of air pollution
Wider context from the report “(3) The adverse effects of air pollution on health are not being sufficiently communicated to patients and their carers by medical and nursing professionals. The evidence at the inquest was that this needs to be addressed at three levels:
a. Undergraduate. I am informed that undergraduate teaching is the responsibility of the GMC, Health Education England and the NMC.
b. Postgraduate. I am informed that postgraduate education is the responsibility of the Royal Colleges, in this case the Royal College of Physicians, the Royal College of Paediatrics and Child Health, the Royal College of General Practitioners, and the NMC.
c. Professional guidance. In this case relevant organisations are NICE and the British Thoracic Society.
” 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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Insufficient detail and monitoring capacity for air quality information
Wider context from the report “(2) There is a low public awareness of the sources of information (such as UK-Air website) about national and local pollution levels. Greater awareness would help individuals reduce their personal exposure to air pollution. It was clear from the evidence at the inquest that publicising this information is an issue that needs to be addressed by national as well as local government. The information must be sufficiently detailed and this is likely to require enlargement of the capacity to monitor air quality, for example by increasing the number of air quality sensors .
” 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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Insufficient professional guidance on communicating the health effects of air pollution
Wider context from the report “(3) The adverse effects of air pollution on health are not being sufficiently communicated to patients and their carers by medical and nursing professionals. The evidence at the inquest was that this needs to be addressed at three levels:
a. Undergraduate. I am informed that undergraduate teaching is the responsibility of the GMC, Health Education England and the NMC.
b. Postgraduate. I am informed that postgraduate education is the responsibility of the Royal Colleges, in this case the Royal College of Physicians, the Royal College of Paediatrics and Child Health, the Royal College of General Practitioners, and the NMC.
c. Professional guidance. In this case relevant organisations are NICE and the British Thoracic Society.
” 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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Low public awareness of sources of national and local pollution information
Wider context from the report “(2) There is a low public awareness of the sources of information (such as UK-Air website) about national and local pollution levels. Greater awareness would help individuals reduce their personal exposure to air pollution. It was clear from the evidence at the inquest that publicising this information is an issue that needs to be addressed by national as well as local government . The information must be sufficiently detailed and this is likely to require enlargement of the capacity to monitor air quality, for example by increasing the number of air quality sensors.
” 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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation National Particulate Matter limits exceeding WHO guideline levels
Wider context from the report “(1) The national limits for Particulate Matter are set at a level far higher than the WHO guidelines. The evidence at the inquest was that there is no safe level for Particulate Matter and that the WHO guidelines should be seen as minimum requirements. Legally binding targets based on WHO guidelines would reduce the number of deaths from air pollution in the UK.
” 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 Publish and promote a position statement on outdoor air quality, including guidance for paediatricians on communicating health impacts and reducing exposure.
Verbatim wording from the response “Our position statement on outdoor air quality in the UK, strongly supports national policies, practices and legislations that aim to improve outdoor air quality and advocates for sharing information and supporting the public to act.⁶ We recognise that everyone has a responsibility for reducing air pollution and have urged paediatricians to be aware of our position on outdoor air quality, and use it to inform patients and their families of the health impacts and encourage and support them to make positive changes to improve air quality and reduce their exposure to air pollution. We also ask that paediatricians act as role models for others and make personal changes to reduce air pollution where possible, and that they encourage change within their workplace and the wider NHS.” Source location 2021-0113-Response-from-Royal-College-of-Paediatrics-and-Child-Health-Redacted
Open published response
Concerns raised 2 Inward-opening doors in confined spaces View source Lack of widespread appreciation of the risks of inward-opening doors in confined spaces View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
LUCY PATRICIA COLGATE · 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
Lucy Patricia Colgate, who had poorly controlled generalised epilepsy, suffered an epileptic fit at home on 28 March 2019 and became wedged behind an inward-opening door in a prone position. She developed positional asphyxia and a hypoxic cardiac arrest before paramedics could free her; the evidence indicated that an outward-opening door was likely to have allowed her to survive, and that this risk was not widely appreciated.
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. The report was sent to Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Inward-opening doors in confined spaces
Wider context from the report “1. ████████ who was Lucy Colgate’s Consultant Neurologist gave evidence that the risks posed to epilepsy sufferers from locked doors is a recognised risk but that the risk posed by having inward opening doors to confined spaces is not widely appreciated. If the door had been outward opening Lucy Colgate is likely to have survived.
” 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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Lack of widespread appreciation of the risks of inward-opening doors in confined spaces
Wider context from the report “1. ████████ who was Lucy Colgate’s Consultant Neurologist gave evidence that the risks posed to epilepsy sufferers from locked doors is a recognised risk but that the risk posed by having inward opening doors to confined spaces is not widely appreciated . If the door had been outward opening Lucy Colgate is likely to have survived.
” 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 Share learning about the death’s circumstances with paediatric specialty groups and OPEN UK to disseminate warnings about these risks.
Verbatim wording from the response “We will share learning around the circumstances of this death with our paediatric specialty groups who lead care for children with epilepsy and with OPEN UK³ (Organisation of Paediatric Epilepsy Networks) to disseminate warnings of these types of risks. We hope” Source location 2021-0042-Response-from-RCPCH-Redacted
Open published response
27 Jan 2021 Michael Chahwanda · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 3 Lack of specific postnatal Vitamin D supplementation advice for attending Health Visitors View source Lack of directive for women at increased risk to take Vitamin D supplements View source Lack of Vitamin D provision to women and babies at increased risk of deficiency View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Michael Chahwanda · 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
Michael Chahwanda was born on 19 September 2018 and died at Royal Manchester Children’s Hospital on 16 December 2018 after suffering a seizure at home. The report states that his death was associated with severe Vitamin D deficiency, with circulatory failure following an out-of-hospital cardiac arrest and cardiomyopathy associated with Vitamin D deficiency recorded at inquest. Concerns included the lack of specific postnatal Vitamin D supplementation advice in the Red Book and the absence of a directive for, or provision of supplements to, women and breast-fed babies at increased risk of deficiency.
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. The report was sent to Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Lack of specific postnatal Vitamin D supplementation advice for attending Health Visitors
Wider context from the report “1. To The Royal College of Paediatrics and Child Health and Department of Health and Social Care and The National Institute for Health and Care Excellence: To consider an amendment to the Red Book to include specific advice for Vitamin D supplementation in the postnatal period to be given by the attending Health Visitor . Such advice would be consistent with national guidance.
” 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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Lack of directive for women at increased risk to take Vitamin D supplements
Wider context from the report “2. To Department of Health and Social Care and The National Institute for Health and Care Excellence : To consider an amendment to the guidelines so that there is a directive for women (particularly those with an increased skin pigmentation and those who are breast-feeding) to take Vitamin D supplements . Also, to consider the provision of Vitamin D to women and babies who are at an increased risk of Vitamin D deficiency.
” 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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Lack of Vitamin D provision to women and babies at increased risk of deficiency
Wider context from the report “2. To Department of Health and Social Care and The National Institute for Health and Care Excellence : To consider an amendment to the guidelines so that there is a directive for women (particularly those with an increased skin pigmentation and those who are breast-feeding) to take Vitamin D supplements. Also, to consider the provision of Vitamin D to women and babies who are at an increased risk of Vitamin D deficiency .
” 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 Publish and ratify guidance recommending vitamin D supplementation for pregnant women, babies and young children.
Verbatim wording from the response “Attached to this letter is the most recent PDF version of the Red Book, version 4.6 most recently updated in August 2020. Please refer to page 6 of this document on Vitamin D that recommends that all pregnant women, babies and young children from birth to 5 years should have a daily supplement containing vitamin D. It states that breastfed babies need vitamin drops from birth alongside breast milk. This is ratified in the College’s own guidance on vitamin D for children.¹” Source location 2021-0020-Response-from-RCPCH-Redacted
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 Existing Red Book, College guidance and professional e-learning already provide vitamin D supplementation advice, so amending the Red Book is unnecessary.
Verbatim wording from the response “You have asked us to consider an amendment to the Red Book to include specific advice for Vitamin D supplementation in the postnatal period to be given by the attending Health Visitor.” Source location 2021-0020-Response-from-RCPCH-Redacted
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 The circumstances indicate a professional practice issue rather than an omission in College standards or guidelines.
Verbatim wording from the response “You have asked us to consider an amendment to the Red Book to include specific advice for Vitamin D supplementation in the postnatal period to be given by the attending Health Visitor.” Source location 2021-0020-Response-from-RCPCH-Redacted
Open published response
Concerns raised 2 Lack of national guidance for close monitoring of mothers and babies following discharge after birth View source Lack of national guidance for medical assessment of a baby when the mother is admitted to hospital with potential sepsis View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Brandon-Robert William Collins-Hayward · 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
Brandon-Robert William Collins-Hayward was born on 29 May 2019 and died on 7 June 2019, aged 9 days, after developing reduced milk intake, a lip shiver, grumbling noises, jaundice, discharge and breathing difficulties. The principal concerns were the lack of national guidance for observations during early postnatal visits and for assessing a baby when the mother is admitted to hospital with infection or possible sepsis.
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. The report was sent to Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance for close monitoring of mothers and babies following discharge after birth
Wider context from the report “i. I am concerned that due to the lack of national guidance regarding close monitoring of mothers and babies following discharge after birth , and the fact that there is no national guidance for a medical assessment of a baby when the mother is admitted to hospital with potential sepsis, there could be a death in the future.
” 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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance for medical assessment of a baby when the mother is admitted to hospital with potential sepsis
Wider context from the report “i. I am concerned that due to the lack of national guidance regarding close monitoring of mothers and babies following discharge after birth, and the fact that there is no national guidance for a medical assessment of a baby when the mother is admitted to hospital with potential sepsis , there could be a death in the future.
” Open source report
Concerns raised 3 Failure of professionals caring for people with Pica to understand its health risks View source Lack of national or professional guidance on identification, assessment and management of Pica and its risks View source Lack of national or professional guidance for monitoring bezoar development in people with Pica View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
James Frankish · 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 Frankish died at Beeches Residential Home after vomiting plant material and expelling a hard plant mass from his stomach into his oesophagus, causing sudden obstruction. The principal concerns were that professionals and care staff did not fully understand or manage the dangers of Pica, and that national or professional guidance was lacking on identifying, assessing and managing Pica and monitoring for bezoar development.
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. The report was sent to Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Failure of professionals caring for people with Pica to understand its health risks
Wider context from the report “(1) Professionals who cared for James did not understand how dangerous Pica can be , ie that it carries significant health risks, including the development of a bezoar . This included the GP, Paediatrician, Psychiatrist, Speech and language therapist, Clinical Psychologist.
” 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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Lack of national or professional guidance on identification, assessment and management of Pica and its risks
Wider context from the report “(2) That there is no national or professional guidance about identification, assessment and management of Pica , with no guidance about how best to understand and manage risk in this condition
” 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 Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Lack of national or professional guidance for monitoring bezoar development in people with Pica
Wider context from the report “(3) That there is no national or professional guidance for monitoring for the possible development of a bezoar in an individual who has Pica .
” Open source report
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations