Robert Gordon John Hogg · Prevention of Future Deaths report

On 25/04/2014 I commenced an Investigation into the death of Robert Gordon John Hogg, a boy aged 2 years. The Investigation concluded at the end of the Inquest on 25th June 2015. The conclusion of the inquest was narrative (see attached).
The medical cause of death was recorded as:-
1a) Acute Bacterial Bronchopneumoniae Streptococcus Pneumoniae Infection Viral Upper Respiratory Tract Infection (Rhinovirus, Human Bocavirus were detected)

Robert Hogg was taken to the Bucks Urgent Care Centre, Stoke Mandeville Hospital on 16.04.14 by his parents with a cold and temperature, he was seen by medical staff and assessed under the NICE guideline to be in the amber category. He was administered antipyretics and was subsequently allowed home when his condition had been assessed in the Green category. Robert’s parents were advised to administer Nurofen, monitor him and bring him back if his condition worsened. Robert was off of his food over 19.04.-20.04.14 eating very little, he was complaining of a stomach ache and grunting when he exhaled. Robert's parents gave him a laxative. He had a bowel movement and appeared to improve.
On 21.04.14 Robert was lethargic, pale and clingy, his mother called 111 and an appointment was made for 13.24 at Bucks Urgent Care Centre, Stoke Mandeville Hospital. While Robert and his family were in the waiting room, he became limp, pale and unresponsive. He was rushed into the Accident and Emergency Department at 13.43 where CPR was commenced. Robert’s death was confirmed by ████████ on 21.04.14 at 14.27.

(1) An Investigation Report (2014/13029) prepared by ████████ for South Central Ambulance Service (Incident No: IR 4865) revealed three areas of concern.
(2) The third area of concern stated specifically “NHS Pathways toddler/child Pathways are not necessarily highlighting/picking up very sick children. This is not the first event relating to incidents involving toddlers/children and this has been highlighted through our own Pathways Lead to NHS Pathways for investigation”
(3) The evidence given by ████████ during the Inquest was that no changes have been made to the toddler/child pathways, and that the third area of concern identified in the Investigation Report is a continuing risk.