Ella Block

On 07/03/2013 I commenced an investigation into the death of Ella Rose Block then aged 4 years. The investigation concluded at the end of the inquest on 06 October 2014. The conclusion of the inquest was NATURAL CAUSES. The medical cause of death was found as 1(a) Reactive Hemophagocytic Syndrome 1 (b) Sepsis due to Unidentified Pathogen

The deceased had previously been seen by her GP. She was admitted to Derriford Hospital on 1 March 2013 unwell and feverish. She deteriorated over night and she sadly died on 2 March 2013.

I am attaching a copy of an individual case review conducted by the Royal College of Paediatrics and Child Health. I would ask you please to confirm that the recommendations are in hand.

In addition, I received evidence from at the Inquest who brought practical matters to my attention.
1. He was concerned that there was poor awareness of Sepsis amongst Junior Doctors. He particularly suggested that junior doctors receive training, i.e. a lecture on Sepsis early in their academic year preferably October before the onset of winter Sepsis. That there be some consideration given to an active poster campaign as the doctor explained to me on the basis of Lord Kitchener “Think of Sepsis”
2. He explained to me as did that there have been organisational changes in Derriford Hospital, in particular a change of Observation Charts known as Paediatric Early Warning Score charts. It was also explained to me that there was a change n procedure in that the Observation Charts are to be reviewed at every changeover of shift.
3. It occurs to me that some paediatric doctors will be working as Locums and there would be merit in standardising the Paediatric Early Warning Score chart at least regionally so that all Locum Doctors are familiar with a standard system. To that end, I am sharing this Notice with the Minister of Health
4. I would ask you please to review the Royal College of Paediatricians and Child health recommendations together with the other practical points raised in this Report and let me know in due curse what steps have been taken. Please feel free to share this Regulation 28 Report with other Hospitals in the region as I am aware of child deaths due to Sepsis in Hospital within the region.