Carla London · Prevention of Future Deaths report

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Issued 6 Jan 2015•North London

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

View original report
Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
1

Described in responses

Recipients and published responses

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.

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

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. Department of Health and Social Care

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

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Department of Health and Social Care

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

    Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
  2. Department of Health and Social Care

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

    Redirects 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 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

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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 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

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

Data last updated 7 September 2026