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William Mead – Root Cause Analysis Investigation Report

South West Published 01 Mar 2015

William Mead from Cornwall died on 14 December 2014, aged 12 months. A coroner’s inquest into William’s death, held on 10 June 2015, identified missed opportunities for an earlier diagnosis and escalation which might have prevented the death of William. A multi-agency investigation was undertaken into the circumstances of William’s death, led by NHS England and Kernow CCG. The findings of the investigation are contained within this Root Cause Analysis report , which makes recommendations for a n

Report PDF NHS England Source
Jump to 14 recommendations

Acceptance status

Per recommendation
No Response Published
14
Total recommendations
14
About this data

Acceptance status tracks whether the trust accepted or responded to each recommendation.

Independent health investigation reports and reviews commissioned by government or NHS England.

About this investigation

Source & metadata

Independent investigation report. Recommendations and any published response are extracted below.

Recommendations

14 total
a) NHS England SSW No Response Published
Recommendation
That NHS England SSW escalates to national bodies the issues relating to the pressure on primary care in relation to: antibiotic prescribing; referrals to secondary care; and workload.
a) NHS England No Response Published
Recommendation
That NHS England identifies existing initiatives such as Care Connect in the SW that will enhance the sharing of patient records and information, and subsequently produces a programme of development for the SW.
a) SWASFT No Response Published
Recommendation
That SWASFT produces an action plan for monitoring.
b) NHS England South No Response Published
Recommendation
That NHS England South escalates the issues regarding the sensitivity of NHS 111 Pathways.
b) SW England No Response Published
Recommendation
That a SW initiative is developed urgently for the dissemination of information to parents and GPs on sepsis recognition as a pilot for the national work as per 14.1[e] above.
b) The Practice No Response Published
Recommendation
That the actions already been taken by the Practice are reviewed to provide assurance that all that should be done from the learning, has been done.
c) NHS England South No Response Published
Recommendation
That NHS England South escalates the issues regarding the need for more defined standards regarding how 111 services and local OOH services interact in regard to dispositions.
c) SW England No Response Published
Recommendation
That a SW initiative is developed for best practice in primary care on safety-netting advice.
c) NHS England SSW No Response Published
Recommendation
That the RCA process and how relatives are involved is reviewed and improved as a result of the positive learning from this case.
d) NHS England South No Response Published
Recommendation
That NHS England South escalates the importance of progressing the information / record-sharing agenda for all NHS bodies.
d) SW England No Response Published
Recommendation
That the SW develops existing plans for referral to assess models of care between primary and secondary care.
e) NHS England Medical Director Office and the UK Sepsis Trust No Response Published
Recommendation
That NHS England Medical Director Office and the UK Sepsis Trust work actively together, with the input of experts and parents in the SW, on the development of national guidance to parents and GPs regarding childhood sepsis, using the SW … Read more
e) SWASFT No Response Published
Recommendation
That SWASFT instigates a plan to train call advisors in probing questions, recognition of complex calls and referrals to clinicians.
f) NHS England No Response Published
Recommendation
That NHS England approaches the CDOP SW to discuss how many cases have been identified involving deaths and the possible reluctance of GPs to prescribe antibiotics.