James David Allbones · Prevention of Future Deaths report

On the 3rd March 2016, I commenced an investigation into the death of James Allbones, aged five. The investigation concluded at the end of the inquest on the 2nd June 2017. The conclusion of the inquest was a Narrative as follows:

James David Allbones died on the 2nd March 2016 at Bassetlaw Hospital from sepsis caused by Influenza B virus infection. He may also have had an additional bacterial infection. The guidelines for the management of sepsis were not followed.

James died from sepsis at Bassetlaw Hospital, Nottinghamshire, within 12 hours of admission. He had been unwell in the days prior to admission, with a cough and breathlessness. The seriousness of his condition was not recognised, and the fluid management required as part of sepsis treatment was not given. There was very limited Consultant management and review of James’ condition, and no early senior consideration of whether James should have been transferred out to another hospital that could provide Paediatric Intensive Care.

Further detail of my findings in relation to these issues is included in the written judgment in this case, which is attached to this document.

• That a child as ill as James will again be moved from the Emergency Department to the ward or Assessment Unit at the Hospital, rather than being transferred out for ongoing care – there is no reassurance that a sick child will be seen by a Consultant Paediatrician in the Emergency Department to assist with this decision
• That the ‘red flag signs’ of sepsis will not be recognised and acted upon by the Paediatric team unless there is further training and awareness raising. I suggest The Paediatric Consultant team access external training and mentoring by senior colleagues ideally within their Critical Care network.
• that there is still no protocol for face to face medical handover
• that the Consultant team have rejected a model of care that encourages frank discussion with nursing and other staff on the ward, aimed at helping all staff speak up when worried about a deterioration child (the RCPCH SAFE model)
• the level of Paediatric staffing at Bassetlaw Hospital. I understand there is often only one junior doctor available, and that the middle grade doctor is on duty for 24 hours.