Prevention of Future Deaths Report: Tommy Gillman (15 April 2024)

Summary

Tommy Gillman died on 8 December 2022 from sepsis and multi organ failure secondary to Salmonella Brandenburg meningitis. There were missed opportunities to provide him with earlier antibiotics, fluid resuscitation and intensive monitoring from 12.35pm on the 7 December 2022 at Kings Mill Hospital. Once the severity of his illness had been recognised at approximately 17:00 hours on that day, he was provided with prompt treatment for septic shock and meningitis. Sadly however he did not respond to this treatment and died the following day following transfer to Leicester Royal Infirmary. Whilst there were serious missed opportunities to provide earlier treatment of sepsis and meningitis.

Content

Matters of concern

1. At times of high pressure and business, the paediatric nursing complement is insufficient in the Emergency Department. There are inexperienced paediatric nurses trying to manage a very high workload, without senior nurse support to try and increase staffing levels on a shift. The Facing the Future (RCPCH) standards for levels of paediatric nursing are not met.
2. Handovers and key conversations between staff, both nursing and medical staff, in ED and with paediatric staff are not routinely documented, and outcomes from handovers and escalations do not result in clear action plans and allocated tasks The repeated serious infections, including with an unusual organism, suggested the possibility of an immune deficiency, but no specific condition was established.  

The system for recognising an ill baby in paediatric ED is not robust – from the point of attendance, through timely triage, timely escalation, and joint assessment by senior ED and paediatric staff.