PFD report

Master Peter Kollar · Prevention of Future Deaths report

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Issued 27 Sep 2017•Inner South 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.

View original report
Concerns
2

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
0

Described in responses

Recipients and published 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.

Concerns raised2

  1. Failure to recognise the seriousness of jaundice in children
  2. Failure to escalate children with jaundice to suitable specialist care
    Part of recurring concern: Failure to obtain timely specialist clinical advice when local expertise is insufficient
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

    Adding jaundice to the Paediatric Early Warning Score is not considered justifiable or effective.

    Stated by Royal College of Emergency MedicineNo action considered necessaryThe respondent said that no further action was needed.

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 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. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

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. ”

Is this part of a recurring concern?

Yes — Failure to obtain timely specialist clinical advice when local expertise is insufficient.

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

Adding jaundice to the Paediatric Early Warning Score is not considered justifiable or effective.

Verbatim wording from the response

“Early Warning Scores are usually developed by rigorous primary research studies. The presence of jaundice after the immediate neonatal period is rare. Many other features that would indicate a seriously ill child are not part of the PEWS, such as abnormal cry or bulging fontanelle. Early Warning Scores are never designed to replace clinical judgement, but merely indicate to a clinician that the patient may be ill. The group unanimously concluded that it would not be justifiable or effective to amend the Paediatric Warning Score to include jaundice.”

Source location

2017-0234-Response-by-The-Royal-College-of-Emergency-Medicine
Page 1 · response
Published 2 October 2017

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