“S are as follows: Children-particularly small infants do not present like adults when…”
Dated 24 Sep 2019, from the coroner for Cambridgeshire and Peterborough. Sent to 3 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 19 Nov 2019. A reply may have been sent and not yet published.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk.
- Report dated24 Sep 2019
- Deadline19 Nov 2019
- Published on judiciary.uk5 Nov 2019
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Public Health England | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 19 Nov 2019. A reply may have been sent and not yet published. |
| NHS 111 | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 19 Nov 2019. A reply may have been sent and not yet published. |
| Herts Urgent care Limited | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 19 Nov 2019. A reply may have been sent and not yet published. |
The coroner’s concerns
S are as follows: Children-particularly small infants do not present like adults when they are very unwell. Nor can they articulate their symptoms in a way that lends itself to prescribed pathway questions and answers and they are not in front of the staff handling the calls who therefore rely on parents for information. Whilst since this event there have been steps to provide training of staff at 111 and Out of Hours services and NHS Digital have reworked the pathways to deal with multiplicity of symptoms there are still concerns re what further steps may be taken regrading cases involving children and infants. Evidence given at the Inquest was that about 20% of calls to both services relate to sick children. There should therefore be robust systems in place to prevent sick children going without potentially lifesaving treatment. Steps should include: 1. Mandatory annual training for all staff on recognising and interpreting signs and symptoms for all staff taking calls needs to be put in place. 2. A suitably qualified paediatric specialist clinician should be available to discuss or review such cases at all times. 3. The default position and precautionary advice should be- if in doubt call an ambulance. 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 19 November 2019. 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, 2019-0311
- 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
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