Recurance · prevention of future deaths reports
Pre-inquest brief
Lack of validated paediatric sepsis screening tool in emergency departments
The earlier warning
Caroline Robey · 16 Oct 2015 · Lydia Brown, Leicester City and Leicestershire South
“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”
judiciary.uk/prevention-of-future-death-reports/caroline-robey
What was promised
Stated action 1 · response to Caroline Robey (16 Oct 2015) · stated 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 2 · response to Caroline Robey (16 Oct 2015) · stated 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 3 · response to Caroline Robey (16 Oct 2015) · stated timescale: none stated
“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.”
1 further stated action is listed on the full chain page.
What recurred
- 13 Feb 2026 · Edward Jones · Oliver Longstaff · Closely related · confidence 0.85 (high)
The clearest link, quoted from both reports:
Earlier · 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”
Later · 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.”
What happened next
No web check of the stated actions has been published for this chain.