Source · Prevention of Future Deaths

Carla London

Ref: 2015-0003 Date: 6 Jan 2015 Coroner: Andrew Walker Area: London (North) Responses identified: 1 / 1 View PDF

Concerns were raised about the need to consider NICE guidance on late-onset sepsis in premature babies and to research infection monitoring systems to improve early detection and treatment.

Date 6 Jan 2015

56-day deadline 3 Mar 2015 est.

Responses identified 1 of 1

Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

Concerns were raised about the need to consider NICE guidance on late-onset sepsis in premature babies and to research infection monitoring systems to improve early detection and treatment.

View full coroner's concerns

20th hrs day:

Her Majesty's Coroner for the Northern District of Greater London (Harrow, Brent; Barnet; Haringey and Enfield) 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 babies and that and for research in to HeRO or other infection monitoring systems,

Responses

1 respondent

Department of Health Central Government

3 Mar 2015 PDF

Action Planned

The Department of Health has shared the coroner's report with NICE, so NICE can take the concerns into account in the development of its guideline on sepsis. NICE expects to publish its final guidance on this topic in July 2016. (AI summary)

View full response

Dear They how sepsis during

Plans include an audit of practice in every GP surgery in England by March 2015,and a new tool for GPs to diagnose sepsis among children under 5. New diagnosis and incentivised treatment for hospitals are also designed to help raise standards. Further information is attached for your convenience and available at: WWW gQV uklgovernmentlnewsInew-action-to-reduce-sepsis We have shared your report with the Centre for Clinical Practice at NICE, so that NICE can take your concerns about this case into account in the development of its guidance in this important area. NICE'$ clinical guideline development process involves an assessment of the available evidence, and consultation with stakeholders NICE is currently developing 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. The new guideline is intended to complement existing NICE guidance on antibiotics for early - onset neonatal infection. This was published in 2012 and outlines best practice for preventing and treating sepsis in infants during the neonatal period. Further information is available at: WWWnice_Org_uklguidancelindevelopmentlgid-cgwave0686 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. that this information is helpful and I thank you for bringing the circumstances of Carla' $ death to our attention_ Best wishes, DR DAN POULTER goals key hope

Report sections

Investigation and inquest

On the 15 Day of April 2014 opened an investigation touching the death of Carla London 12 days old: The inquest concluded on the 21st November 2014_ The conclusion of the inquest was Natural Causes' the medical case of death was Ia E Coli septicaemia Ib Extreme Prematurity

Circumstances of the death

Carla was born on the 14/h April 2011 weighing 970 gms in hospital. On the April Carla was given a course of antibiotics for a suspected sepsis_ The antibiotics were stopped on the 24th April 2011. During the afternoon of the 25lh April 2011 Carla was noticed to be unwell by her mother and was reassured by a nurse. Carla was recognised to be unwell by the staff on the morning of the 26th April 2011 and rapidly deteriorated and died in hospital at 14.30 on the same Expert evidence heard at the inquest suggested that there should be NICE guidance on late onset sepsis in under 1500 gms babies and that and for research in to HeRO or other infection monitoring systems.

Action should be taken

In my opinion action should be taken to prevent future deaths and believe you [ANDIOR your organisation] have the power to take such action.

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Shared signals

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Report details

Reference: 2015-0003
Date of report: 6 January 2015
Coroner: Andrew Walker
Coroner area: London (North)

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 3 Mar 2015 (estimated).

Sent to

Department of Health and Social Care

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.