Date of report: 28 February 2020

Ref: 2020-0046

Deceased name: Lewys Crawford

Coroners name: Graeme Hughes

Coroners Area: South Wales Central

Category: Hospital Death (Clinical Procedures and medical management) related deaths; Wales prevention of future deaths reports (2019 onwards)

This report is being sent to: Cardiff and Vale University Health Board

Matters of concern:

  1. A potential deficiency in the knowledge and understanding of A & E Consultants covering in the paediatric A & E Department (whilst there is no on site consultant in paediatric emergency medicine) in the identification/diagnosis of sepsis in babies and very young children. Whilst it is appreciated that the quest to recruit further consultants in paediatric emergency medicine to provide more comprehensive cover in the Department continues, until such time as a sufficient complement is in place, and A & E Consultants provide some of the cover, the Health Board must ensure that those that do, are urgently and adequately trained to a competent standard to deliver the care required. It cannot be simply left to the individual consultants to determine their own requirements in this regard. As their employers, the Health Board, has an overarching obligation to ensure that competent staff are employed and to maintain high professional standards.
  2. There needs to be a greater understanding of, and reference to the NICE Sepsis risk stratification tool: children aged under 5 years in hospital by Clinicians and Nurses in both the A & E & Paediatric depts. Whilst it is appreciated that the finalisation of a bespoke sepsis tool, based upon the UK Sepsis Trust’s Tools and Pathways is awaited, until such time as its adopted, the Health Board needs to address apparent lapses in the understanding of what is required upon diagnosis of a potentially septic baby/child, particularly in the period between triage and admission to the ward. Specifically, the importance of stabilising the patient prior to transfer by completing a full septic screen. Furthermore, the Inquest highlighted gaps in the understanding and knowledge of agency nurses as to the septic screen and the steps to be followed. The Health Board needs a clear policy (and to ensure this is implemented & followed) to ensure that agency nurses are up to date with their training and understanding in this area of practice.
  3. Guidance and instruction to both clinicians and nurses as to the appropriate use (and recording) of terminology should be considered in suspected sepsis patients. There was a degree of confusion in both the A & E & Paediatric Departments caused by the interchangeable use of sepsis and bacterial
    infection as to what treatment should be initiated/progressed depending on which description was used. If sepsis is suspected, that clear and continuing reference ought to be maintained, if, and until it is superseded by an alternative diagnosis.
  4. In suspected sepsis patients, particularly babies, guidance and instruction needs to be emphasised to clinicians & nurses as to alternative methods of administration of antibiotics. Evidence at Inquest demonstrated that there were failures to consider alternatives to cannulation for IV antibiotics, such as intramuscularly or intra-osseously.

Regulation 28: Report to prevent future deaths: Lewys Crawford
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Regulation 28: Report to prevent future deaths: Lewys Crawford – Courts and Tribunal Judiciary
Regulation 28: Report to prevent future deaths: Lewys Crawford
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