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Ignorance about sepsis was a factor in child’s death, says report

BMJ 2016; 352 doi: https://doi.org/10.1136/bmj.i541 (Published 27 January 2016) Cite this as: BMJ 2016;352:i541
A revised version of the investigation report referred to in this news story is available on NHS England's website
  1. Ingrid Torjesen
  1. 1London

England’s health secretary, Jeremy Hunt, has said that he will look into whether more clinicians are needed to staff the urgent care service NHS 111, after a report into the death of 1 year old William Mead from septicaemia in December 2014 found that four opportunities for preventing his death were missed.

The family’s general practice in Cornwall and the NHS 111 telephone helpline failed to diagnose and act on the septicaemia that was responsible for his death and the pneumonia that led to it, says the report, seen by The BMJ. Although the review panel concluded that “these did not constitute serious failings by the individuals involved,” had different courses of action been taken, even those at a late stage, William would probably have survived.

In particular, the report concluded that GPs and parents need more information on the key signs of septicaemia and that NHS 111 call advisers should get more training in what questions to ask and when to escalate cases.

Hunt has made a public apology to William’s parents and pledged that lessons would be learnt from the incident. Responding to an MP’s question about the death in the House of Commons on 26 January, he said, “While any health organisation will inevitably suffer some tragedies, the issues raised in this case have significant implications for the rest of the NHS, from which I am determined that we should learn,” he said. “Most of all, we must recognise that our understanding of sepsis across the NHS is totally inadequate.”

Though it wasn’t appropriate for every NHS 111 call to be answered by a clinician, Hunt said, all centres had clinicians on hand. “We will certainly look at whether we need to have more clinicians in 111.” But he added, “My own view is that it is the separation of the out-of-hours services and the 111 service that is at the heart of the problem that we are looking to deal with.”

The investigation report said that the first significant missed opportunity was that staff at the family’s GP surgery did not recognise and treat the underlying pathology, a chest infection and pneumonia. His mother took William to the surgery repeatedly between September and December 2014, with symptoms that included regular vomiting, fever, a rash, and a persistent cough, but these visits did not seem to have raised the GPs’ “index of suspicion.”

As septicaemia took hold, services missed opportunities to refer William to hospital urgently. On Friday 12 December William was sent home from nursery, agitated, not eating, and with a high temperature, and his GP failed to assess his heart rate, which if it had been raised would have indicated a high risk of serious illness. The report said, “The post-mortem and inquest concluded that at this time the sepsis would have been established and empyema would have been present, so it is likely that the heart rate would have been raised.”

The next day William seemed tired and was vomiting a lot more. His mother made a 14 minute call to NHS 111 for advice, and the call adviser went down the “Vomiting and/or Nausea” pathway to the “Speak to Primary Care Service within 6 hours” disposition. The report said that the call adviser was working to a script of questions and was “trained to not deviate from this” and that there was missed potential during the telephone triage to have asked further questions that may have led to a two hour disposition being applied. “If a 2- hour disposition had been applied and fulfilled, the out-of-hours GP would have heard William crying and concluded that an urgent referral to hospital was required,” the report said.

An out-of-hours GP did phone William’s mother three hours later and asked if she would like to bring William to the clinic, but by this time William was asleep. She asked the GP for his professional advice, which was to let William sleep. Had William been seen it is possible that the GP might have picked up on the severity of the illness, the report said. However, the GP did not recognise the significance of a large drop in temperature as a significant sign. William was dead the next morning.

The panel made some observations with national implications, including that, if the out-of-hours GP had had access to William’s primary care records and seen details of the boy’s attendances over the previous weeks, he might well have decided to insist on seeing William.

In terms of the NHS 111 service, “call advisers need to be trained to appreciate when there is a need to probe further, how to recognise a complex call, and when to call in clinical advice earlier,” the report said. The NHS 111 pathways also had “limited sensitivity to red flags relating to sepsis and to subtle changes in a deteriorating paediatric patient,” it added. “The significance of a rapid drop in temperature is also not a factor recognised in the pathway.”

Finally for national consideration was the ongoing challenge of shared patient records. The panel concluded that, if the out-of-hours GP had had access to the primary care records and details of the attendances of William over the previous weeks, he might well have decided to insist on seeing William on the Saturday.

The panel commented that, although the GPs involved did not cite workload pressure or the constant pressure to reduce antibiotic prescribing and numbers of referrals to acute care hospitals, these were ongoing issues in primary care. The panel added that the “safety netting” advice given by the GPs to the parents was of the standard normally given by primary care but “was inadequate and needs to be improved” and should be enhanced at weekends to compensate for reduced availability of medical support.

The fact that many GPs would not be aware that a rapid and dramatic drop in temperature was an indication of rapid deterioration needed to be dealt with, the report said.

Notes

Cite this as: BMJ 2016;352:i541

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