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Stephen Durkin, a factory worker from Hereford, died after suffering organ failure from sepsis. The life-threatening condition occurs when the immune system overreacts to an infection, causing widespread inflammation that can damage the body’s own tissue. Michelle Durkin complained about delays in the diagnosis and treatment of sepsis which led to her husband Stephen’s death. She said that the Trust did not carry out proper observations, put him under the critical care team or transfer him to intensive care quickly enough. She also complained that the Trust did not communicate effectively with her about her husband’s condition which meant she was unable to say goodbye to him. Findings The PHSO detailed its findings as follows: Our investigation found that the Trust should have detected sepsis earlier than it did. The Trust did not follow its own deteriorating patient policy to observe the patient every four to six hours within the first 48 hours. National guidance on NEWS states that if the NEWS increases, the frequency of observations should also increase. By the time the Trust saw Stephen, his NEWS had increased significantly. It is highly likely that more frequent observations would have detected this deterioration earlier, which would have prompted the Trust to consider how to treat Stephen’s worsening condition. We found that even when the Trust did detect the deterioration, it did not react appropriately. According to national guidance, it is essential for patients with a NEWS of seven or more to be assessed by a critical care team. The Trust did not do this until ten hours later, when Stephen’s NEWS was nine. We also found that the Trust did not effectively communicate with Michelle about her husband’s condition. When she called the ward, she was not told how unwell he was. If she had been, she could have got to the hospital sooner. We found this would have given her an opportunity to better prepare herself for what was to come, but this option was taken away from her. Recommendations Following PHSO recommendations, the Trust has agreed to: write to Michelle to acknowledge the failings identified in our report and apologise for the impact they had on her. explain what action it will take to ensure all relevant staff involved in Stephen’s care receive training in sepsis awareness. pay Michelle £17,000 in recognition of the injustice she suffered as a result of its failings.

In her report, the Coroner states his main concerns as follows: Informed consent and maternal choice regarding mode of delivery That this appears to be a recurring theme in obstetric practice. The culture in this area appears to still not fully accept the principles of informed consent set down in case law of the appeal courts (Montgomery) and in NICE guidance (Caesarean Section). It also does not seem to prioritise the wishes of pregnant women or holding full and frank discussions about the risks and benefits and pros and cons of different options. He noted that he had concerns that situations might arise, like it appears happened in Rhian’s case, where maternal requests are being made for re-consideration of the mode of delivery owing to feelings of physical weakness, pain or developing ill health. Evidence heard at Rhian’s inquest demonstrated that there was very little, if indeed any, recorded (in medical records) discussion held between midwives/obstetricians and Rhian regarding mode of delivery, maternal wishes and risk and benefits of differing management plans. Infection risk of retained foetus following feticide That a significant infection risk (retention of a deceased foetus) is not being given due weight in clinical decisions when a mother is attending for delivery (following feticide). There does not appear to be any specific or detailed local, or indeed national, guidance, for obstetricians and midwives which addresses this issue or discusses important considerations such as whether infection can be controlled by antibiotics alone or whether swifter methods of foetal delivery, such as a caesarean section, should be considered, or indeed whether specific microbiology advice needs to be obtained as part of a multi-disciplinary team approach. That while cases such as Rhian’s may be rare, consideration could be given as to whether more detailed and specific guidance should be made available to assist clinicians when treating mothers in maternity units following feticide. This report was sent to Worcestershire Acute Hospitals NHS Trust, Birmingham Women and Children’s Hospital NHS Trust, the Royal College of Obstetricians and Gynaecologists and the Healthcare Safety Investigation Branch.

In her report, the Coroner states her main concerns as follows: Ms Bruce was cared for in the community by several different District Nurses. This meant that it was not the same nurse who was always seeing the wound. No photographs were taken for reference and the electronic records could not be accessed by the District Nurses while they were in Ms Bruce’s home. This meant that all information that could have been available was not, meaning Ms Bruce’s change in condition was not fully appreciated. Leicestershire Partnership Trust has learned from this and District Nurses now have work mobile phones so that they can take photographic evidence of wounds as well as IT technology that means they can access the electronic records while they are with the patient. In addition, they also have a ‘sepsis’ bag containing equipment to record a patient's blood pressure, oxygen saturation levels and temperature. Although this lesson has been learned and changes made to prevent future deaths locally, the concern is that the practice that was in place at the time of Ms Bruce’s death may be practice elsewhere. This report was sent to the Department of Health and Social Care, Leicestershire Partnership NHS Trust and University Hospital of Leicester NHS Trust.

Findings Findings of this investigation included: The existing systems for triage do not always take into account the colour of a patient’s skin. This may influence a healthcare professional’s assessment of an infant’s/child’s physical signs. Staffing standards that relate to the treatment of children in emergency departments cannot always be met due to workforce challenges, particularly in hospitals without a dedicated paediatric emergency department. Sometimes parents describe feeling powerless when trying to articulate their concerns for their child. Some healthcare professionals do not always consider or listen to what parents are telling them. The Association of Ambulance Chief Executives are not currently involved in the ongoing national work to develop early warning scores for infants and children. Undergraduate training for paramedics on the identification of sick infants/children is variable across England. There is inconsistency across English ambulance services in training for ambulance personnel, including paramedics and non-registered clinicians, on the identification of sick infants/children. Recommendations The report makes the following safety recommendations: HSIB recommends that the Chair of the NHS System-wide Paediatric Observations Tracking (SPOT) Programme ensures that the Association of Ambulance Chief Executives, community NHS 111 providers and primary care services are integral members of the NHS SPOT Programme. HSIB recommends that NHSX develops national standards describing the electronic deployment of the NHS System-wide Paediatric Observations Tracking (SPOT) e-PEWS (the digital version of the Paediatric Early Warning Score tool), in collaboration with the NHS England and NHS Improvement SPOT Programme. This should include specifications for data capture, calculation of the score and escalation status, and also the display of the information and connectivity with other digital systems. HSIB recommends that the Chair of the NHS System-wide Paediatric Observations Tracking (SPOT) Programme ensures that any resources produced include examples of children and young people with non-white skin showing signs of serious illness. HSIB recommends that the Association of Ambulance Chief Executives works together with the ambulance services to share best practice in relation to paediatric training, education resources, frequency and types of training, and that it collates and shares areas of best practice. HSIB recommends that the College of Paramedics works with partners and higher education providers to develop, agree and implement standards for paediatric education for the future ambulance service workforce. Response from Patient Safety Learning Patient Safety Learning welcomes the publication of this new report by HSIB looking at ways to improve patient safety in relation to recognition of the acutely ill infant and child. Our reflections on this report are as follows: Increased collaboration within the NHS SPOT Programme We welcome HSIB’s recommendation that the NHS SPOT Programme should ensure it includes involvement from the Association of Ambulance Chief Executives, community NHS 111 providers and primary care services. The tragic circumstances of Mohammad’s death clearly emphasise the important role that each of these different services can play in the process of recognising life-threatening bacterial infections in very young patients. Health inequalities This investigation specifically draws attention to how existing systems for triage in primary and secondary care are not always considering the colour of a young patient’s skin, noting the impact this may have on a healthcare professionals’ assessment of physical signs. The report indicates that the importance of considering how symptoms and signs can present differently on dark skin has been highlighted in Mind the Gap: A handbook of clinical signs in Black and Brown skin. They also refer to the ongoing work of the Skin Deep Project, which aims to develop a free, open-access bank of high-quality photographs of medical conditions in a range of skin tones for use by both healthcare professionals and the public. We welcome HSIB’s specific recommendation that the SPOT programme should seek to ensure its resources include examples of children and young people with non-white skin showing signs of serious illness. We know however that safety issues faced by patients due to the colour of their skin are not limited to these specific cases. In line with the ambition set out in the NHS Long Term Plan to take a more concerted and systematic approach to “reducing health inequalities and addressing unwarranted variation in care”, we believe this should be a priority issue for the NHS National Patient Safety Team. We would like to see them working together with the Dr Bola Owolabi, Director – Health Inequalities at NHS England and NHS Improvement, to scope a potential programme of work in this area. Listening to parents The report highlights communication concerns from Mohammad’s parents, noting “the family’s perception is that they trusted what staff were telling them but that they were ultimately not listened to”. This remains a recurring problem in healthcare and emerges time and again in patient safety failings. Too often concerns raised by patients and family members are not acted on and, when harm occurs, they are left out of the investigation process. In our report, A Blueprint for Action, we set out what we believe is needed to progress towards a patient-safe future, identifying six foundations of safe care. Patient engagement is one of those six foundations. In this, we outline how patients should be engaged for safety at the point of care, if things go wrong, in improving services, advocating for changes and in holding the system to account. The value of early warning scores The report highlights that research shows that existing early warning scores are not sensitive or specific enough to help health professionals to distinguish between a seriously unwell infant/child and one with a mild viral illness. It states that “changes in vital signs (for example temperature, heart rate and respiratory rate) may be predictors of deterioration in an infant or child but they may also simply reflect that a child is unwell but not at significant risk”. We find it surprising therefore that there is not a reflection or recommendation on the need to support clinicians in their assessment of deteriorating patients, such as the further development of early warning scores. Review of ambulance service training The report notes the following safety observation: “It may be beneficial if the 10 English ambulance services review and assess their paediatric training provision and report this assessment to their trust board.” HSIB explains this observation is intended to “identify all clinical staff working in the ambulance service that have accessed ‘Spotting the sick child’ or equivalent training as an education resource and find out how often it has been accessed, and to highlight any gaps in training needs for recognition of the acutely ill infant/child”. It is our view that it would be preferable for this to be a specifically cited safety recommendation for implementation and response.