PFD report

Carla London · Prevention of Future Deaths report

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Issued 6 Jan 2015•North London

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
1

Described in responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Report evidence summary

Concerns raised2

  1. Failure to consider NICE guidance on late onset sepsis in babies under 1500 g
    Part of recurring concern: Unreliable neonatal infection guidance
  2. Lack of research into HeRO or other infection monitoring systems
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    Local maternity and neonatal providers determine how services are delivered in their areas, having regard to NICE guidance.

    Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to consider NICE guidance on late onset sepsis in babies under 1500 g

Wider context from the report

“That coroner shares the concerns expressed by the independent expert that consideration should be given to NICE guidance on late onset sepsis in under 1500 gms babies and that and for research in to HeRO or other infection monitoring systems. ”

Is this part of a recurring concern?

Yes — Unreliable neonatal infection 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. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of research into HeRO or other infection monitoring systems

Wider context from the report

“That coroner shares the concerns expressed by the independent expert that consideration should be given to NICE guidance on late onset sepsis in under 1500 gms babies and that and for research in to HeRO or other infection monitoring systems. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Local maternity and neonatal providers determine how services are delivered in their areas, having regard to NICE guidance.

Verbatim wording from the response

“Local maternity and neonatal care providers determine how best to deliver services in their area. In doing so we would always expect them to give due regard to NICE guidance.”

Source location

2015-0003-Response-by-Department-of-Health
Page 2 · response
Published 6 January 2015

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. 1

    Share the coroner’s report with NICE for consideration during development of its sepsis guidance.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 6 January 2015.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    NICE will decide whether its sepsis guidance should assess the HeRo heart-rate monitoring system and similar systems.

    Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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 coroner’s report with NICE for consideration during development of its sepsis guidance.

Verbatim wording from the response

“We have shared your report with the Centre for Clinical Practice at NICE, so that NICE can take your concerns about this account into account in the development of its guidance in this important area. NICE’s clinical guideline development process involves an assessment of the available evidence, and consultation with key stakeholders.”

Source location

2015-0003-Response-by-Department-of-Health
Page 2 · response
Published 6 January 2015

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

NICE will decide whether its sepsis guidance should assess the HeRo heart-rate monitoring system and similar systems.

Verbatim wording from the response

“NICE is currently developing a clinical guideline on sepsis which will cover the recognition, diagnosis and management of severe sepsis in people of all ages. NICE will decide whether this should include an assessment of the HeRo heart rate monitoring system and other such systems. NICE currently expects to publish its final guidance on this topic in July 2016.”

Source location

2015-0003-Response-by-Department-of-Health
Page 2 · response
Published 6 January 2015

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Official responses located
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Data last updated 7 September 2026