Jacob Owczarek
28 Jul 2021 · Coroner Dr Elizabeth Didcock · Nottinghamshire
This report repeats 1 earlier warning, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. low compliance with paediatric sepsis screening tool
“Continuing low compliance with the Paediatric sepsis screening tool”
2. lack of named responsible consultant review prior to discharge
“Lack of Named/Responsible Consultant review prior to a child's discharge”
3. absence of alert system for ICE results
“No alert/review system for ICE results yet in place for all the Paediatric team”
4. lack of documentation of radiology discussion about child
“No current system for recording a discussion about a child, in the Radiology meetings (where important investigations are planned)”
5. login issues with locum doctors
“The risk of continuing Login issues when Locum doctors are working at the Trust”
Linked reports
Closely relatedConfidence 0.85 · high
Earlier report
“No clinician took clear responsibility for discharge decision making. The recording of the identity of the discharging clinician was incorrect and communication between clinicians and nursing staff was unclear.”
This report
“Lack of Named/Responsible Consultant review prior to a child's discharge”
Closely relatedConfidence 0.80 · moderate
This report
“No current system for recording a discussion about a child, in the Radiology meetings (where important investigations are planned)”
Later report
“There is no clear internal policy/procedure within Doncaster Royal Infirmary for disseminating either an addendum report and/or the information contained within the addendum report from the external third party radiology service to the treating clinical team.”
Responses
2021-0259-Response-from-Doncaster-and-Bassetlaw-Teaching-Hospitals-NHS-Foundation-Trust_Published.pdf ↗· Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Stated action · Q3 pilot
“A sepsis audit tool Task and Finish group with MDT input from both Paediatric and ED teams has been set up to review the audit tool for sepsis management, which will audit the pathway from the point of arrival in the Emergency Department. Due to the complexity of the different referral pathways this is a complex audit tool to develop, it is currently in the final stages of development, the aim is to pilot this in Q3. For Q2 the current audit tool will be used.”