“Poor communication on a number of levels Insufficient discussion with the parents…”

The coroner’s concerns

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— (1) Poor communication on a number of levels Insufficient discussion with the parents regarding history, insufficient weight attached to the information they did provide at the time of admission and subsequently. Absence of any protocols of guidance as to how best to communicate with children with disabilities such as autism as MJ had. Communications between staff were poor, HCAs to nurses, nurses to doctors and between junior doctors and senior doctors. Ineffective communication of microbiology results which had been phoned through to the ward but not immediately passed on to those who needed to undertake assessment. (2) PAWS The observation chart was poorly completed. There were occasions where incorrect scoring had been documented understating MJ’s condition at that time. This was a form and source of information said to have been heavily relied upon but no clear protocols for doctors to regularly review and assess. It would seem further training is required to ensure accurate completion of this form and accurate scoring. (3) Sepsis in Paediatrics It is clear that consideration should be given to developing a protocol and guidance for those treating children. A paediatric screening tool needs to be provided. There needs to be clear explanations of the terms septic, sepsis, septic shock, septicaemia, bacteraemia. These terms were used interchangeably. It needs to be made clear to staff the signs they should be looking out for and how these might be responded to. (4) Dissemination of key information and medical updates There needs to be a review of the systems currently in place for disseminating such information. | was not reassured from the evidence | heard that the current system is effective in that regard or fully understood by staff at the trust. (5) Poor record keeping Even when a ward is busy, it is imperative that clear records are made of significant events or developments. There were a number of occasions where no record was made at all Coroner's Court and Office, Doncaster Crown Court, College Road, Doncaster, DN1 3HS Tel 01302 737135 | Fax 01302 736365 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you, Mr Mike Pinkerton, The Chief Executive has the power to take such action.

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, 2016-0045

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