Concerns raised 12 Failure to transmit allergy action plans to schools View source Lack of standardisation of allergy action plans across hospitals and schools View source Omission of second adrenaline auto-injector guidance from the emergency call algorithm View source Failure to ensure that school medication is in date View source Lack of awareness that a second adrenaline auto-injector should be administered after deterioration or non-improvement View source Delays in time-critical asthma and allergy review appointments View source Lack of school pupil understanding of allergies and the consequences of allergen exposure View source Failure to check or audit school allergy care plans and medication boxes View source Lack of awareness that adrenaline should be administered immediately for respiratory compromise after allergen exposure View source Insufficient availability of two adrenaline auto-injectors at all times View source Failure to communicate emergency adrenaline instructions effectively in school staff training View source Absence of emergency adrenaline instructions on EpiPen packaging View source See 9 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.
×
AI-generated summary
Karanbir Singh CHEEMA · 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
Karanbir Singh CHEEMA, a pupil at William Perkin High School with multiple food allergies and asthma, went into anaphylactic shock after another pupil threw cheese at him on 28 June 2017 and died. Concerns included inadequate awareness of his allergies, insufficient checking and availability of EpiPens, an out-of-date EpiPen, failures in sharing and standardising allergy action plans, a cancelled follow-up appointment, and shortcomings in emergency response guidance and training.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Failure to transmit allergy action plans to schools
Wider context from the report “5. The allergy action plan drafted by Karanbir’s doctors at Ealing Hospital did not find its way to his school . There is no standardised approach to this , for example always sending a copy to the school designated safeguarding lead, as well as giving parents/carers a copy for themselves and a copy for the school in case the posted version does not arrive.
” 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 standardisation of allergy action plans across hospitals and schools
Wider context from the report “4. Allergy action plans are not standardised across hospitals and schools , so messages are not as clearly delivered as they could be . This is vital particularly when they may be read for the first time in a desperate situation where panic has set in.
” 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 Omission of second adrenaline auto-injector guidance from the emergency call algorithm
Wider context from the report “11. The London Ambulance Service 999 operator did not at any time suggest that a second EpiPen be given , because this is not contained within the algorithm . That could be remedied internationally.
” 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 that school medication is in date
Wider context from the report “3. Karanbir’s EpiPen was out of date . There must be systems in place to ensure that medication in schools is in date .
” 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 awareness that a second adrenaline auto-injector should be administered after deterioration or non-improvement
Wider context from the report “8. There appears to be a lack of awareness nationally of the simple but vital messages that:
- if a person with an allergy has been exposed to an allergen and develops any respiratory compromise, so any breathing difficulty at all, then adrenaline (via EpiPen or other) should be administered immediately, before any asthma pump and even before calling for help;
- if there is a deterioration after giving one EpiPen, then another should be administered immediately, or in any event after five minutes if there is no improvement .
” 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 time-critical asthma and allergy review appointments
Wider context from the report “6. Karanbir’s treating doctors wanted him to re-attend for asthma and allergy review four months after his last consultation. An appointment was made but cancelled by the hospital . By the time of his death four months later he had still not been seen again . There needed to be recognition of the time critical nature of this appointment. It needed to be re-booked without 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 Lack of school pupil understanding of allergies and the consequences of allergen exposure
Wider context from the report “1. The pupils at Karanbir’s school had a patchy understanding of his allergies, what they were and the consequences of exposure to allergens . Targeted education about this would improve safety.
” 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 check or audit school allergy care plans and medication boxes
Wider context from the report “2. Karanbir’s school care plan and medical box were not checked or audited to ensure, for example, that his care plan stipulated two EpiPens® (adrenaline auto-injectors), the box contained two EpiPens.
” 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 awareness that adrenaline should be administered immediately for respiratory compromise after allergen exposure
Wider context from the report “8. There appears to be a lack of awareness nationally of the simple but vital messages that:
- if a person with an allergy has been exposed to an allergen and develops any respiratory compromise, so any breathing difficulty at all, then adrenaline (via EpiPen or other) should be administered immediately , before any asthma pump and even before calling for help;
- if there is a deterioration after giving one EpiPen, then another should be administered immediately, or in any event after five minutes if there is no improvement.
” 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 availability of two adrenaline auto-injectors at all times
Wider context from the report “7. Karanbir had one EpiPen at home, one at school and one at his father’s home . There is clearly a need for medical teams to emphasise that two EpiPens must be available at all times .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of Paediatrics and Child Health; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate emergency adrenaline instructions effectively in school staff training
Wider context from the report “10. These instructions were not communicated effectively as part of the school staff’s first aid and EpiPen training .
” 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 Absence of emergency adrenaline instructions on EpiPen packaging
Wider context from the report “9. The EpiPen box does not contain these instructions on the outside .
” Open source report
Concerns raised 2 Failure to recognise the seriousness of jaundice in children View source Failure to escalate children with jaundice to suitable specialist care 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
Master Peter Kollar · 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
Master Peter Kollar, a young child, presented to hospital with diarrhoea and jaundice but was diagnosed with carotenemia and discharged without blood tests, investigation, admission or consultant escalation. An expert raised concern that jaundice in children after the neonatal period was under-recognised and that failure to escalate a child with jaundice to an appropriate specialist could adversely affect care and be potentially life threatening. Peter died aged 3½ from multi-organ failure with pulmonary haemorrhage following acute liver failure and an unidentified inborn error of metabolism, with viral infections also recorded; the conclusion was natural causes.
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 recognise the seriousness of jaundice in children
Wider context from the report “████████ Professor of Paediatric Hepatology, Birmingham gave an expert opinion. She said that jaundice is rare in children after the neonatal period and that its seriousness was under recognised by both paediatricians and emergency doctors . She considered that, whilst it made no difference to the outcome in this case, the non escalation of a young child with jaundice to a suitable specialist adversely affects their care and is potentially life threatening. There will be instances when a child presents with a primary liver cause of hepatic failure where prompt referral for support and the possibility of organ transplantation was critical.
” 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 escalate children with jaundice to suitable specialist care
Wider context from the report “████████ Professor of Paediatric Hepatology, Birmingham gave an expert opinion. She said that jaundice is rare in children after the neonatal period and that its seriousness was under recognised by both paediatricians and emergency doctors. She considered that, whilst it made no difference to the outcome in this case, the non escalation of a young child with jaundice to a suitable specialist adversely affects their care and is potentially life threatening . There will be instances when a child presents with a primary liver cause of hepatic failure where prompt referral for support and the possibility of organ transplantation was critical .
” Open source report
30 Jun 2016 baby Dominic Smith · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 14 Failure to act on early warning scores View source Failure to carry out maternal observations after delivery despite a temperature spike View source Failure to recognise signs and symptoms of neonatal deterioration View source Inadequate clinical communication and handover View source Inadequate preceptorship for newly qualified and part-time midwives View source Failure of midwives to escalate to or consult with relevant specialist clinicians View source Failure to carry out speculum examination to establish rupture of membranes View source Failure to document rationale for clinical discretion View source Failure to carry out neonatal observations after material change in condition View source Failure to routinely offer intrapartum prophylactic antibiotics to women with current or previous positive GBS tests View source Failure of staff to follow clinical protocols and guidance View source Failure to routinely offer antenatal GBS screening to pregnant women during the final weeks of pregnancy View source Miscalculation of early warning scores View source Inadequate clinical record keeping View source See 11 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
baby Dominic Smith · 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 Dominic Smith was born on 2 June 2015 after a prolonged labour and died at approximately 18 hours of life following a collapse. The report describes pneumonia as the cause of death and identifies concerns including failure to recognise possible rupture of membranes and infection risk, inadequate maternal and neonatal observations, failure to escalate deterioration, delayed antibiotic treatment, and communication and record-keeping problems.
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 act on early warning scores
Wider context from the report “Pennine Acute Hospitals NHS Trust:
1. During the course of the inquest into Baby Smith’s death, the following concerns arose:
- Inadequate communication, handover and record keeping;
- Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion;
- Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes. The time between rupture and delivery was, more likely than not, miscalculated as a result of this;
- Early warning scores were i) miscalculated, ii) not acted upon ;
- Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition. Signs and symptoms relating to the deterioration were also missed;
- Maternal observations were not carried out after delivery, despite a spike in temperature;
- Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist
&
- Inadequate preceptorship for newly qualified (and particularly part-time) Midwives.
” 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 carry out maternal observations after delivery despite a temperature spike
Wider context from the report “Pennine Acute Hospitals NHS Trust:
1. During the course of the inquest into Baby Smith’s death, the following concerns arose:
- Inadequate communication, handover and record keeping;
- Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion;
- Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes. The time between rupture and delivery was, more likely than not, miscalculated as a result of this;
- Early warning scores were i) miscalculated, ii) not acted upon;
- Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition. Signs and symptoms relating to the deterioration were also missed;
- Maternal observations were not carried out after delivery, despite a spike in temperature ;
- Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist
&
- Inadequate preceptorship for newly qualified (and particularly part-time) Midwives.
” 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 signs and symptoms of neonatal deterioration
Wider context from the report “Pennine Acute Hospitals NHS Trust:
1. During the course of the inquest into Baby Smith’s death, the following concerns arose:
- Inadequate communication, handover and record keeping;
- Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion;
- Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes. The time between rupture and delivery was, more likely than not, miscalculated as a result of this;
- Early warning scores were i) miscalculated, ii) not acted upon;
- Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition. Signs and symptoms relating to the deterioration were also missed ;
- Maternal observations were not carried out after delivery, despite a spike in temperature;
- Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist
&
- Inadequate preceptorship for newly qualified (and particularly part-time) Midwives.
” 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 clinical communication and handover
Wider context from the report “Pennine Acute Hospitals NHS Trust:
1. During the course of the inquest into Baby Smith’s death, the following concerns arose:
- Inadequate communication, handover and record keeping;
- Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion;
- Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes. The time between rupture and delivery was, more likely than not, miscalculated as a result of this;
- Early warning scores were i) miscalculated, ii) not acted upon;
- Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition. Signs and symptoms relating to the deterioration were also missed;
- Maternal observations were not carried out after delivery, despite a spike in temperature;
- Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist
&
- Inadequate preceptorship for newly qualified (and particularly part-time) Midwives.
” 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 preceptorship for newly qualified and part-time midwives
Wider context from the report “Pennine Acute Hospitals NHS Trust:
1. During the course of the inquest into Baby Smith’s death, the following concerns arose:
- Inadequate communication, handover and record keeping;
- Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion;
- Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes. The time between rupture and delivery was, more likely than not, miscalculated as a result of this;
- Early warning scores were i) miscalculated, ii) not acted upon;
- Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition. Signs and symptoms relating to the deterioration were also missed;
- Maternal observations were not carried out after delivery, despite a spike in temperature;
- Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist
&
- Inadequate preceptorship for newly qualified (and particularly part-time) Midwives .
” 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 midwives to escalate to or consult with relevant specialist clinicians
Wider context from the report “Pennine Acute Hospitals NHS Trust:
1. During the course of the inquest into Baby Smith’s death, the following concerns arose:
- Inadequate communication, handover and record keeping;
- Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion;
- Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes. The time between rupture and delivery was, more likely than not, miscalculated as a result of this;
- Early warning scores were i) miscalculated, ii) not acted upon;
- Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition. Signs and symptoms relating to the deterioration were also missed;
- Maternal observations were not carried out after delivery, despite a spike in temperature;
- Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist
&
- Inadequate preceptorship for newly qualified (and particularly part-time) Midwives.
” 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 carry out speculum examination to establish rupture of membranes
Wider context from the report “Pennine Acute Hospitals NHS Trust:
1. During the course of the inquest into Baby Smith’s death, the following concerns arose:
- Inadequate communication, handover and record keeping;
- Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion;
- Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes . The time between rupture and delivery was, more likely than not, miscalculated as a result of this;
- Early warning scores were i) miscalculated, ii) not acted upon;
- Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition. Signs and symptoms relating to the deterioration were also missed;
- Maternal observations were not carried out after delivery, despite a spike in temperature;
- Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist
&
- Inadequate preceptorship for newly qualified (and particularly part-time) Midwives.
” 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 document rationale for clinical discretion
Wider context from the report “Pennine Acute Hospitals NHS Trust:
1. During the course of the inquest into Baby Smith’s death, the following concerns arose:
- Inadequate communication, handover and record keeping;
- Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion ;
- Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes. The time between rupture and delivery was, more likely than not, miscalculated as a result of this;
- Early warning scores were i) miscalculated, ii) not acted upon;
- Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition. Signs and symptoms relating to the deterioration were also missed;
- Maternal observations were not carried out after delivery, despite a spike in temperature;
- Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist
&
- Inadequate preceptorship for newly qualified (and particularly part-time) Midwives.
” 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 carry out neonatal observations after material change in condition
Wider context from the report “Pennine Acute Hospitals NHS Trust:
1. During the course of the inquest into Baby Smith’s death, the following concerns arose:
- Inadequate communication, handover and record keeping;
- Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion;
- Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes. The time between rupture and delivery was, more likely than not, miscalculated as a result of this;
- Early warning scores were i) miscalculated, ii) not acted upon;
- Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition . Signs and symptoms relating to the deterioration were also missed;
- Maternal observations were not carried out after delivery, despite a spike in temperature;
- Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist
&
- Inadequate preceptorship for newly qualified (and particularly part-time) Midwives.
” 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 intrapartum prophylactic antibiotics to women with current or previous positive GBS tests
Wider context from the report “Department of Health, NIHCE and the Royal Colleges:
1. I previously completed a PFD 13 month ago in relation to a neonatal GBS death. At that time I raised the following concerns:
- That antenatal screening for GBS was not being routinely offered by the NHS to all pregnant women during the final weeks of pregnancy,
- That prophylaxis intrapartum antibiotics were not routinely offered to all women who test positive for GBS (or have done so in the past)
&
- That given the seriousness of the illness, in the absence of a national screening and prophylactic treatment programme, babies were potentially being put at risk of harm/death.
During the course of the inquest into Baby Smith’s death the evidence suggested that no further action has been taken in this regard, despite the responses received in relation to the last PFD action.
I therefore raise the issues again as a concern.
” 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 staff to follow clinical protocols and guidance
Wider context from the report “Pennine Acute Hospitals NHS Trust:
1. During the course of the inquest into Baby Smith’s death, the following concerns arose:
- Inadequate communication, handover and record keeping;
- Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion;
- Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes. The time between rupture and delivery was, more likely than not, miscalculated as a result of this;
- Early warning scores were i) miscalculated, ii) not acted upon;
- Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition. Signs and symptoms relating to the deterioration were also missed;
- Maternal observations were not carried out after delivery, despite a spike in temperature;
- Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist
&
- Inadequate preceptorship for newly qualified (and particularly part-time) Midwives.
” 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 antenatal GBS screening to pregnant women during the final weeks of pregnancy
Wider context from the report “Department of Health, NIHCE and the Royal Colleges:
1. I previously completed a PFD 13 month ago in relation to a neonatal GBS death. At that time I raised the following concerns:
- That antenatal screening for GBS was not being routinely offered by the NHS to all pregnant women during the final weeks of pregnancy ,
- That prophylaxis intrapartum antibiotics were not routinely offered to all women who test positive for GBS (or have done so in the past)
&
- That given the seriousness of the illness, in the absence of a national screening and prophylactic treatment programme, babies were potentially being put at risk of harm/death.
During the course of the inquest into Baby Smith’s death the evidence suggested that no further action has been taken in this regard, despite the responses received in relation to the last PFD action.
I therefore raise the issues again as a concern.
” 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 Miscalculation of early warning scores
Wider context from the report “Pennine Acute Hospitals NHS Trust:
1. During the course of the inquest into Baby Smith’s death, the following concerns arose:
- Inadequate communication, handover and record keeping;
- Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion;
- Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes. The time between rupture and delivery was, more likely than not, miscalculated as a result of this;
- Early warning scores were i) miscalculated , ii) not acted upon;
- Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition. Signs and symptoms relating to the deterioration were also missed;
- Maternal observations were not carried out after delivery, despite a spike in temperature;
- Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist
&
- Inadequate preceptorship for newly qualified (and particularly part-time) Midwives.
” 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 clinical record keeping
Wider context from the report “Pennine Acute Hospitals NHS Trust:
1. During the course of the inquest into Baby Smith’s death, the following concerns arose:
- Inadequate communication, handover and record keeping ;
- Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion;
- Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes. The time between rupture and delivery was, more likely than not, miscalculated as a result of this;
- Early warning scores were i) miscalculated, ii) not acted upon;
- Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition. Signs and symptoms relating to the deterioration were also missed;
- Maternal observations were not carried out after delivery, despite a spike in temperature;
- Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist
&
- Inadequate preceptorship for newly qualified (and particularly part-time) Midwives.
” 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 Routine antenatal GBS screening is not recommended because evidence of mortality benefit is lacking and screening may cause maternal, neonatal and antimicrobial harms.
Verbatim wording from the response “The UK National Screening Committee does not recommend routine screening of all pregnant women for GBS carriage. We note that the National Screening Committee is due to review this recommendation again in 2015/16.” Source location 2016-0240-Response-by-RCPCH
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 NHS Trust, rather than the College, is responsible for responding on local communication, record keeping, policies and procedures.
Verbatim wording from the response “Given that we do not have all the details of the tragic death of Baby Smith, the RCPCH is unable to comment on the specifics of the case and the Pennine Acute Hospitals NHS Trust has been asked to respond directly on local communication, record keeping and policies and procedures.” Source location 2016-0240-Response-by-RCPCH
Open published response
7 May 2015 Baby Olsberg · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 3 Risk of serious harm or death to babies from GBS infection View source Failure to routinely offer prophylactic intrapartum antibiotics to women with current or previous positive GBS tests View source Failure to routinely offer antenatal GBS screening to all pregnant women during the final weeks of pregnancy 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 Olsberg · 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 Olsberg was born on 23 December 2013 and developed worsening symptoms in the hours after birth. Despite medical treatment and transfer to tertiary care, he suffered three cardiac arrests and died on 24 December 2013; blood cultures confirmed GBS infection. The concerns identified were the lack of routine antenatal GBS screening and routine prophylactic intrapartum antibiotics, and the resulting potential risk of serious harm or death to babies.
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 Risk of serious harm or death to babies from GBS infection
Wider context from the report “3. That GBS infection is a very serious illness and in the absence of a national screening and prophylactic treatment programme, babies are potentially being put at risk of harm/death .
” 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 prophylactic intrapartum antibiotics to women with current or previous positive GBS tests
Wider context from the report “2. That prophylactic intrapartum antibiotics are not routinely offered to all women who test positive for GBS (or have done so in the past) .
” 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 antenatal GBS screening to all pregnant women during the final weeks of pregnancy
Wider context from the report “1. That antenatal screening for GBS is not routinely offered by the NHS, to all pregnant women, during the final weeks of pregnancy .
” Open source report
12 Sep 2014 Evelyn Mary Smith · Prevention of Future Deaths report Warwickshire
View report summary
Concerns raised 5 Failure to accurately and consistently record vital signs View source Lack of clinician knowledge of the croup severity scoring system View source Lack of paediatric expertise in the sole clinical contact for children attending A&E View source Difficulty entering Paediatric Early Warning Scoring information into GP medical records View source Failure of the GP computer system to alert clinicians to complete clinically relevant parameters View source See 2 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.
×
AI-generated summary
Evelyn Mary Smith · 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
Evelyn Mary Smith was 7 years old when she died after an acute deterioration in her breathing at home on 13 September 2013, following several healthcare consultations for croup-like symptoms. A post-mortem examination identified Parainfluenza Virus Type 2 and Staphylococcus Aureus, resulting in Acute Ulcerative Laryngotracheobronchitis. The principal concern was that a relatively inexperienced paediatric doctor was the only clinical contact for a child attending A&E, and that discussion with the paediatric team might have led to longer observation and consideration of non-viral causes.
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 accurately and consistently record vital signs
Wider context from the report “(1) The care provided to Miss Smith was reviewed by an independent paediatrician and a General Practitioner. I heard evidence that the accurate and consistent recording of Miss Smith’s vital signs may have allowed earlier recognition of the severity of her illness . I also heard that the use of the Paediatric Early Warning Scoring system in General Practice may be a useful way of documenting this information. However, it was clear that information in this form is not easy to enter into GP medical records.
(2) From the evidence heard at Miss Smith’s inquest it was apparent that the scoring system for croup severity was not widely known amongst the clinicians involved in her care. However, her GP did learn of this scoring system after reviewing the ‘clinical mentor’ tool through the practice’s computer software.
I heard evidence that systems are in place to prompt entry of certain clinical parameters in specific scenarios; predominantly chronic disease review consultations, such as for diabetes and asthma etc. I am concerned that the GP computer system contains important and clinically relevant information, such as the croup severity score but does not alert the clinician to complete it. I heard that it should be possible to prompt the entry of relevant clinical parameters after a diagnostic code has been entered into a consultation record.
” 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 clinician knowledge of the croup severity scoring system
Wider context from the report “(1) The care provided to Miss Smith was reviewed by an independent paediatrician and a General Practitioner. I heard evidence that the accurate and consistent recording of Miss Smith’s vital signs may have allowed earlier recognition of the severity of her illness. I also heard that the use of the Paediatric Early Warning Scoring system in General Practice may be a useful way of documenting this information. However, it was clear that information in this form is not easy to enter into GP medical records.
(2) From the evidence heard at Miss Smith’s inquest it was apparent that the scoring system for croup severity was not widely known amongst the clinicians involved in her care . However, her GP did learn of this scoring system after reviewing the ‘clinical mentor’ tool through the practice’s computer software.
I heard evidence that systems are in place to prompt entry of certain clinical parameters in specific scenarios; predominantly chronic disease review consultations, such as for diabetes and asthma etc. I am concerned that the GP computer system contains important and clinically relevant information, such as the croup severity score but does not alert the clinician to complete it. I heard that it should be possible to prompt the entry of relevant clinical parameters after a diagnostic code has been entered into a consultation record.
” 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 paediatric expertise in the sole clinical contact for children attending A&E
Wider context from the report “(1) The care provided to Miss Smith was reviewed by an independent paediatrician, who raised concerns regarding the paediatric experience of the FY2 doctor in A&E . His concern was that, whilst the care provided was not manifestly inappropriate or incorrect, he considered that discussion with the paediatric team may have prompted a longer period of observation and consideration of non-viral causes of croup-like signs. I share his overarching concern that a doctor, relatively inexperienced in paediatrics, should be the only clinical contact for a child taken to A&E .
I heard from the Hospital Trust that mandating all FY2 doctors to have postgraduate experience in paediatrics, before they were allocated to work in A&E, might have significant resource implications and may not be feasible.
” 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 Difficulty entering Paediatric Early Warning Scoring information into GP medical records
Wider context from the report “(1) The care provided to Miss Smith was reviewed by an independent paediatrician and a General Practitioner. I heard evidence that the accurate and consistent recording of Miss Smith’s vital signs may have allowed earlier recognition of the severity of her illness. I also heard that the use of the Paediatric Early Warning Scoring system in General Practice may be a useful way of documenting this information. However, it was clear that information in this form is not easy to enter into GP medical records .
(2) From the evidence heard at Miss Smith’s inquest it was apparent that the scoring system for croup severity was not widely known amongst the clinicians involved in her care. However, her GP did learn of this scoring system after reviewing the ‘clinical mentor’ tool through the practice’s computer software.
I heard evidence that systems are in place to prompt entry of certain clinical parameters in specific scenarios; predominantly chronic disease review consultations, such as for diabetes and asthma etc. I am concerned that the GP computer system contains important and clinically relevant information, such as the croup severity score but does not alert the clinician to complete it. I heard that it should be possible to prompt the entry of relevant clinical parameters after a diagnostic code has been entered into a consultation record.
” 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 the GP computer system to alert clinicians to complete clinically relevant parameters
Wider context from the report “(1) The care provided to Miss Smith was reviewed by an independent paediatrician and a General Practitioner. I heard evidence that the accurate and consistent recording of Miss Smith’s vital signs may have allowed earlier recognition of the severity of her illness. I also heard that the use of the Paediatric Early Warning Scoring system in General Practice may be a useful way of documenting this information. However, it was clear that information in this form is not easy to enter into GP medical records.
(2) From the evidence heard at Miss Smith’s inquest it was apparent that the scoring system for croup severity was not widely known amongst the clinicians involved in her care. However, her GP did learn of this scoring system after reviewing the ‘clinical mentor’ tool through the practice’s computer software.
I heard evidence that systems are in place to prompt entry of certain clinical parameters in specific scenarios; predominantly chronic disease review consultations, such as for diabetes and asthma etc. I am concerned that the GP computer system contains important and clinically relevant information, such as the croup severity score but does not alert the clinician to complete it . I heard that it should be possible to prompt the entry of relevant clinical parameters after a diagnostic code has been entered into a consultation record.
” Open source report
1 Apr 2014 Oliver George Hiscutt · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 1 Lack of mandatory formal paediatric training for GPs 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
Oliver George Hiscutt · 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
Oliver George Hiscutt developed a Group A beta-haemolytic streptococcal infection with a retropharyngeal abscess, followed by catastrophic haemorrhage and cardiac arrests; he died on 7 October 2012. The report raised concern that formal paediatric or child-health training is not mandatory for GPs and that exposure to acute paediatrics during GP training is limited.
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 mandatory formal paediatric training for GPs
Wider context from the report “Currently it is not mandatory for GPs to undertake formal paediatric / child health training. Facing the Future (2011) states that there are currently 10 000 GP trainees in the country and less than 25% of them will undertake any paediatric placement during their training. GP trainees who do undertake a paediatric placement during their training gain a range of educational benefits such as the development of skills in spotting the sick child, specialist management of children with long term conditions and multi disciplinary team working.
The Royal College of General Practitioners and the Royal College of Paediatrics and Child Health strongly support all GPs having exposure to acute paediatrics as part of their vocational training. Offering every GP trainee a hospital post in paediatrics within the current 3 year specialty training programme is undeliverable. The Royal College of General Practitioners makes the case that there should be an enhanced 4 year programme of GP training and that all GPs should undertake specialist led paediatric training. Specialist led paediatric training will ensure that future GPs have the skills and experience they need to assess and respond effectively and safely to sick children, to better co-ordinate the care of children with long term conditions and to safeguard those at risk.
” Open source report
Concerns raised 5 Lack of effective supervision of non-career grade paediatricians without previous experience View source Lack of independent consultant assessment of paediatric admissions outside normal working hours View source Failure to acknowledge or act on parent concerns View source Lack of consultant supervision of out-of-hours on-call paediatric trainees View source Lack of effective application of national guidelines for assessment and investigation of fever in children less than one year of age 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
Jackson J Chadd · 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
Jackson became unwell at home with fever, poor feeding, diarrhoea, a rash and abnormal observations, and was discharged from A&E with a diagnosis of gastroenteritis. He returned in septic shock and died despite resuscitation; the medical cause of death was fulminant meningococcal infection. Concerns included inadequate supervision and assessment, failure to apply fever guidelines, and failure to act on a parent’s concerns.
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 effective supervision of non-career grade paediatricians without previous experience
Wider context from the report “1. Lack of effective supervision of a non-career grade paediatrician with no previous experience
” 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 independent consultant assessment of paediatric admissions outside normal working hours
Wider context from the report “3. Lack of independent consultant assessment of paediatric admissions into Frimley Park Hospital outside normal working 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 acknowledge or act on parent concerns
Wider context from the report “5. Failure to acknowledge or act on the concerns of a parent
” 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 consultant supervision of out-of-hours on-call paediatric trainees
Wider context from the report “2. Lack of consultant supervision of ‘out of hours’ on-call paediatric trainees
” 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 effective application of national guidelines for assessment and investigation of fever in children less than one year of age
Wider context from the report “4. Lack of effective application of national guidelines for assessment and investigation of fever in children less than one year of age
” 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 Review the consultant-review standard, collate supporting evidence, and consider increasing consultant reviews from once to twice daily within 24 hours.
Verbatim wording from the response “The ‘Facing the Future’ standards were audited in 2012 by RCPCH for compliance by units across the UK. We found standard 1 was met by 77.4% of units and standard 2 by 87.7%. 99.2% met standard 3. Although this case may have been compliant with our existing standards, our audit report indicated that we were proposing to reconsider standard 2 amongst others with a view to increasing the frequency of consultant review to twice rather than once in 24 hours. This review has now commenced and will take around three months during which we will collate any evidence available to support the recommendations made. In parallel I have discussed this matter with Professor Reid at Health Education England, and as a result our workforce team is working with HEE to model the implications for medical staffing across the country were we to recommend twice daily consultant review.” Source location 2014-0137-Response-by-Royal-College-of-Paediatrics-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 Audit compliance with the Facing the Future paediatric service standards across UK units.
Verbatim wording from the response “The ‘Facing the Future’ standards were audited in 2012 by RCPCH for compliance by units across the UK. We found standard 1 was met by 77.4% of units and standard 2 by 87.7%. 99.2% met standard 3. Although this case may have been compliant with our existing standards, our audit report indicated that we were proposing to reconsider standard 2 amongst others with a view to increasing the frequency of consultant review to twice rather than once in 24 hours. This review has now commenced and will take around three months during which we will collate any evidence available to support the recommendations made. In parallel I have discussed this matter with Professor Reid at Health Education England, and as a result our workforce team is working with HEE to model the implications for medical staffing across the country were we to recommend twice daily consultant review.” Source location 2014-0137-Response-by-Royal-College-of-Paediatrics-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 Model with Health Education England the national medical-staffing implications of recommending twice-daily consultant review.
Verbatim wording from the response “The ‘Facing the Future’ standards were audited in 2012 by RCPCH for compliance by units across the UK. We found standard 1 was met by 77.4% of units and standard 2 by 87.7%. 99.2% met standard 3. Although this case may have been compliant with our existing standards, our audit report indicated that we were proposing to reconsider standard 2 amongst others with a view to increasing the frequency of consultant review to twice rather than once in 24 hours. This review has now commenced and will take around three months during which we will collate any evidence available to support the recommendations made. In parallel I have discussed this matter with Professor Reid at Health Education England, and as a result our workforce team is working with HEE to model the implications for medical staffing across the country were we to recommend twice daily consultant review.” Source location 2014-0137-Response-by-Royal-College-of-Paediatrics-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 The hospital Trust is responsible for addressing local policies, their implementation, staff practice and competence, including parental concerns.
Verbatim wording from the response “Given that we do not have all the details of the case presented the RCPCH is unable to comment on the specifics of the case. We have presumed that the hospital Trust will be responding on local policies and procedures and their implementation relating to the above, and will be reviewing and addressing any issues pertaining to the personal practice and competence of the staff involved.” Source location 2014-0137-Response-by-Royal-College-of-Paediatrics-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 The case may have complied with existing paediatric supervision standards, although review of those standards is being undertaken.
Verbatim wording from the response “The ‘Facing the Future’ standards were audited in 2012 by RCPCH for compliance by units across the UK. We found standard 1 was met by 77.4% of units and standard 2 by 87.7%. 99.2% met standard 3. Although this case may have been compliant with our existing standards, our audit report indicated that we were proposing to reconsider standard 2 amongst others with a view to increasing the frequency of consultant review to twice rather than once in 24 hours. This review has now commenced and will take around three months during which we will collate any evidence available to support the recommendations made. In parallel I have discussed this matter with Professor Reid at Health Education England, and as a result our workforce team is working with HEE to model the implications for medical staffing across the country were we to recommend twice daily consultant review.” Source location 2014-0137-Response-by-Royal-College-of-Paediatrics-Child-Health
Open published response
Concerns raised 3 Lack of consultant supervision of emergency paediatric admissions by on-call trainees or sub-consultant paediatric doctors View source Lack of independent consultant assessment of paediatric admissions View source Lack of national guidelines for assessment and investigation of headaches in children 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
Lucy Maria GOULDING · 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 Goulding was admitted to hospital on 26 June 2013 with worsening headaches, later collapsed and suffered a cardiorespiratory arrest, and was confirmed dead on 27 June 2013 after emergency treatment for a brain tumour. The principal concerns were inadequate consultant supervision and independent assessment of paediatric admissions, and the lack of national guidelines for assessing and investigating headaches in children.
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 consultant supervision of emergency paediatric admissions by on-call trainees or sub-consultant paediatric doctors
Wider context from the report “1. Lack of consultant supervision of on-call paediatric trainees or sub-consultant paediatric doctors admitting paediatric patients as an emergency into Worthing 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 Lack of independent consultant assessment of paediatric admissions
Wider context from the report “2. Lack of independent consultant assessment of paediatric admissions into Worthing Hospital in and outside normal working 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 Lack of national guidelines for assessment and investigation of headaches in children
Wider context from the report “3. Lack of national guidelines for assessment and investigation of headaches in children
” 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