Caroline Robey
16 Oct 2015 · Coroner Lydia Brown · Leicester City and Leicestershire South
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of sepsis screening tool
“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”
2. non adoption of patient safety alert
“Apatient safety alert issued 2 September 2014 by NHS England clearly sets out resources available in the provision of a UK sepsis clinical tool kit, but this had not been recognised or adopted by the health care providers involved in this case.”
3. inadequate recording of frequent attendances
“Inadequate note was taken of the number of different attendances Mrs [name redacted] had initiated despite previous good health, and there was no suggestion she was a frequent attender or had ever sought medical assistance inappropriately”
Linked reports
Closely relatedConfidence 0.85 · high
This report
“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 report
“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.”
Responses
2015-0376-Response-from-NHS-England.pdf ↗· NHS England
Stated action · 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.”
ROBEY-Responses.pdf ↗· East Midlands Ambulance Service
Stated action · 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 · 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.”