Lila Marsland
This report repeats 1 earlier warning, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of full embedding of Child Sepsis Screening Tool
“Having carefully considered the oral evidence given in court by a range of different clinicians with varying roles and remits, I am concerned that, notwithstanding the work the Trust has undertaken in response to [the deceased]'s death, the Child Sepsis Screening Tool is not yet fully embedded in the minds of those who assess and treat Children and Young People at the Trust”
2. lack of full implementation of NG240 guideline
“I am concerned that the Trust is yet to fully implement the latest iteration of the National Institute of Health and Care Excellence's Guideline Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management (NG240 Published 19 March 2024)”
3. locum consultant signed 'Safe to Transfer' without examination
“It is a matter of concern that the Locum Consultant in Emergency Medicine who completed a form indicating [the deceased] was 'Safe to Transfer' to the Paediatric Emergency Department did so without undertaking any examination or direct assessment of her”
4. absence of medical record of examination by Locum Registrar in Paediatrics
“I am concerned that no medical record appears to exist of the examination of [the deceased] which was undertaken by the Locum Registrar in Paediatrics which resulted was discharged from hospital”
5. lack of full embedding of Child Sepsis Screening Tool
“the Child Sepsis Screening Tool is not yet fully embedded in the minds of those who assess and treat Children and Young People at the Trust”
6. fragmented and disjointed information storage and sharing
“over the course of almost 10 hours in hospital, [the deceased]'s history and details of examinations and assessments undertaken were recorded on a mixture of various analogue and digital systems in operation in different parts of the Trust, leading to a risk of vital clinical information being lost in the system”
Linked reports
Earlier report
“was recruited as a locum registrar by the Hospital Trust without there appearing to have been any assessment of his skills and abilities or any supervision of him at the hospital.”
This report
“I am concerned that no medical record appears to exist of the examination of [the deceased] which was undertaken by the Locum Registrar in Paediatrics which resulted was discharged from hospital.”
This report
“over the course of almost 10 hours in hospital, [the deceased]'s history and details of examinations and assessments undertaken were recorded on a mixture of various analogue and digital systems in operation in different parts of the Trust, leading to a risk of vital clinical information being lost in the system.”
Later report
“Having reviewed Miss [name redacted] in the Same Day Emergency Care Unit on 5 October 2025, the Orthopaedic Senior House Officer wrote their notes in a Trauma and Orthopaedic 'Tracker', not routinely accessible to clinicians working in other specialities.”
Responses
2025-0291-Response-from-Department-of-Health-and-Social-Care.pdf ↗· Department of Health and Social Care
2025-0291-Response-from-Tameside-and-Glossop-Integrated-Care-NHS-Foundation-Trust.pdf ↗· Tameside and Glossop Integrated Care NHS Foundation Trust