“The inquest was told it is acknowledged nationally that there is no Sepsis Screening Tool…”

The coroner’s concerns

– The inquest was told it is acknowledged nationally that there is no Sepsis Screening Tool which is validated for use in Paediatric Emergency Departments or has a sensitivity or specificity which makes it a useful tool for escalation within a Paediatric Emergency Department. LTHT has developed a Sepsis Screening Tool (SST) which is designed to be used by relatively junior nursing staff to improve the likelihood of considering sepsis and therefore requesting a senior medical review. The SST is intended to be completed at admission or if there is a clinical deterioration, such as an increase in PAWS score to 10 or above. 5 The tool contains various checkbox items that if present suggest a high risk of sepsis. These include abnormal respiratory rate, mottling, rash or appearing blue, high heart rate, low blood pressure, altered conscious level and parental or health professional concern. High temperature needs to be 38 degrees C or more and then only in patients less than 4 months old so is less discriminatory. There are secondary checkbox items indicating a moderate risk of sepsis including new leg pain, cold extremities, reduced urine output and temperature at any age greater than 39 degrees C. A single positive score mandates urgent assessment by a senior decision maker defined as a doctor of ST4 grade or higher, or equivalent allied health professional and if sepsis is confirmed to ensure prompt management, including giving IV antibiotics within 60 minutes. The SST tool is not designed to diagnose sepsis directly as this is the task of the senior decision maker but rather to prompt a targeted assessment, which will confirm sepsis or specifically eliminate it. Acknowledging that the trust’s SST had not been deployed in any assessment of Edward that was undertaken in the LGI PED, a trust witness told the inquest that work was ongoing to ensure a consistent application of the SST as between the PED and the paediatric in-patient units at the Leeds Children’s Hospital. As a coroner making a report of this nature, it is not for me to recommend to any third party that the Sepsis Screening Tool developed by the Leeds Teaching Hospitals Trust, or any document like it, should be either more widely disseminated to, or adopted as official guidance for, Paediatric Emergency Departments across England and Wales. 6

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, 2025-0633

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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