“A RCA revealed a number of failings by the Trust including in respect of some matters…”

The coroner’s concerns

– A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NMEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NMEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017. Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness. The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions. Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 23 November 2018. I, the coroner, may extend the period.

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, 2018-0329

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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