Lack of validated paediatric sepsis screening tool in emergency departments
NHS England received 2 coroners' reports about this hazard between 16 Oct 2015 and 13 Feb 2026.
They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.
A published response was found for 1 of the 1 earlier reports, stating 4 specific actions.
The story, report by report
Spacing grows with the time between reports.
“No sepsis screening tool was being used by the community health care providers, and so opportunities were lost to consider a diagnosis of sepsis and refer as an emergency for hospital admission and treatment”
Original on judiciary.uk ↗ NHS England responded, stating 4 specific actions.Response (PDF) ↗Response (PDF) ↗
“In March 2015 EMAS introduced an updated sepsis screening tool (both adult and paediatric) based upon the Sepsis 6 red flags and NHS England Safety Alert (2014) (appendices 1a and 1b).”
Stated timescale: March 2015
“A patient safety alert was issued on the 2 September 2014 by NHS England clearly sets out the resources available in the provision of a UK Sepsis clinical tool kit, but this has not be recognised or adopted by health care providers in this case.”
Stated timescale: January 2016
2 more stated actions in the Promises tab.
- 10 years 4 months laterClosely relatedConfidence 0.85 · higha different coroner
“there is no Sepsis Screening Tool which is validated for use in Paediatric Emergency Departments or has a sensitivity or specificity which makes it a useful tool for escalation within a Paediatric Emergency Department.”
Original on judiciary.uk ↗ Repeated from the earlier report:SepsisScreeningToolEmergency
NHS England responded.Response (PDF) ↗
- All reports to NHS England
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2015 → 2026Edward Jones10 years 4 months after Caroline Robey · different coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight the absence of a sepsis screening tool that could help identify sepsis early. The earlier report concerns community healthcare providers, while the later report concerns paediatric emergency departments.
Caroline Robey · 16 Oct 2015
“No sepsis screening tool was being used by the community health care providers, and so opportunities were lost to consider a diagnosis of sepsis and refer as an emergency for hospital admission and treatment”
Original on judiciary.uk ↗ Edward Jones · 13 Feb 2026
“there is no Sepsis Screening Tool which is validated for use in Paediatric Emergency Departments or has a sensitivity or specificity which makes it a useful tool for escalation within a Paediatric Emergency Department.”
Original on judiciary.uk ↗
Stated action · timescale: March 2015
“In March 2015 EMAS introduced an updated sepsis screening tool (both adult and paediatric) based upon the Sepsis 6 red flags and NHS England Safety Alert (2014) (appendices 1a and 1b).”
Stated action · timescale: January 2016
“A patient safety alert was issued on the 2 September 2014 by NHS England clearly sets out the resources available in the provision of a UK Sepsis clinical tool kit, but this has not be recognised or adopted by health care providers in this case.”
Stated action
“Inadequate note was made of the number of different attendances Mrs [name redacted] had initiated despite previous good health, and there is no suggestion that she was a frequent attender or had ever sort medical attention inappropriately.”
Stated action · timescale: next appraisal
“The PAG considered the case and concluded that the following actions should be undertaken: - has been requested to reflect on his record keeping at his next appraisal and on the diagnosis and treatment of patients with suspected sepsis.”
No specific action could be extracted with a verified quote.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to NHS England at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2015 → 2026 | 0.75 | 0.28 | Closely related · 0.85 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.