“To the Chief Executive, Tameside and Glossop Integrated Care NHS Foundation Trust 1”

The coroner’s concerns

– To the Chief Executive, Tameside and Glossop Integrated Care NHS Foundation Trust 1. 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 Lila’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. 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. It is a matter of concern that the Locum Consultant in Emergency Medicine who completed a form indicating Lila was ‘Safe to Transfer’ to the Paediatric Emergency Department did so without undertaking any examination or direct assessment of her. The doctor had previously filed a statement at court indicating he had undertaken a ‘preliminary visual assessment’ of Lila, but accepted in oral evidence that this was not, in fact, the case; 4. I am concerned that no medical record appears to exist of the examination of Lila which was undertaken by the Locum Registrar in Paediatrics which resulted was discharged from hospital. The absence of this key piece of evidence serves to limit the ability of the Trust to derive all possible learning from Lila’s death. To the Secretary of State for Health and Social Care The court heard evidence that, over the course of almost 10 hours in hospital, Lila’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. I am concerned that this, and other hospitals elsewhere in the country, continue to operate with information being stored and shared between professionals in a fragmented and disjointed way.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2025-0291

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0