Source · Prevention of Future Deaths
James Allbones
Ref: 2017-0336
Date: 21 Jul 2017
Coroner: Elizabeth Didcock
Area: Nottinghamshire
0 responses identified · 3 indexed addressees
View PDF
AI-generated concerns summaryThe coroner noted insufficient consultant paediatrician review for sick children moved from the Emergency Department to wards, a lack of training on sepsis 'red flags', and no face-to-face medical handover protocol. Inadequate paediatric staffing levels were also identified.
Date
21 Jul 2017
56-day deadline
27 Jan 2018 est.
estimated from the Judiciary.uk publication date
Responses identified
0 of 3
Coroner's concerns
The coroner noted insufficient consultant paediatrician review for sick children moved from the Emergency Department to wards, a lack of training on sepsis 'red flags', and no face-to-face medical handover protocol. Inadequate paediatric staffing levels were also identified.
View full coroner's concerns
In the circumstances it is therefore my statutory duty to report to you: Essentially the serious and outstanding That child as 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 recognized and acted upon by the Paediatric team unless there is further training and awareness raising. suggest The Paediatric Consultant team access external_training and_mentoring by and and days senior colleagues ideally within their Critical 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 deteriorating child (the RCPCH SAFE model) the level of Paediatric staffing at Bassetlaw Hospital. understand there is often only one junior doctor available, and that the middle grade doctor is on duty for 24 hours_
Report sections
Circumstances of the death
James died from sepsis at Bassetlaw Hospital, Nottinghamshire, within 12 hours of admission. He had been unwell in the 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:
Action should be taken
In my opinion, action should be taken to prevent future deaths and | believe you have the power to take such action
Similar PFD reports
Report details
- Reference
- 2017-0336
- Date of report
- 21 July 2017
- Coroner
- Elizabeth Didcock
- Coroner area
- Nottinghamshire
Responses identified
Responses identified
0 of 3
3 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 27 Jan 2018 (estimated from the Judiciary.uk publication date).
Sent to
- Bassetlaw Clinical Commissioning Group
- Care Quality Commission
- Doncaster and Bassetlaw Hospital NHS Trust