“Junior staff not knowing when to escalate concerns 2”
Dated 10 May 2023, from the coroner for South Yorkshire West. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
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All responses publishedOrganisations 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; a reply may have been sent and not yet published.
- Report dated10 May 2023
- Deadline5 Jul 2023
- Published on judiciary.uk18 Oct 2023
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Sheffield Children's NHS Foundation TrustNamed in the report as “Sheffield Children’s NHS Foundation Trust” | Response publishedPublished on judiciary.uk in October 2023. |
The coroner’s concerns
– 1. Junior staff not knowing when to escalate concerns 2. Unclear guidance in the handbook relating to chicken pox and reinfection and the need for aggressive antibiotic treatment if reinfection occurs soon after the initial infection 3. Confirmation bias affecting clinical reviews 4. Lack of proper assessment of existing skin lesions in chicken pox even where identified by parents 5. Lack of knowledge of the risk of secondary complications from recent chicken pox infection in the emergency department 6. Insufficient weight on GP referral when not through the identified route of referral (ie presentation straight to A&E which amounts to 25% of referrals). I heard evidence that an IT system is in development to resolve this however engagement of NHS Digital and the Commissioners is required to progress. For the avoidance of doubt, had the GP referral been processed in the usual way James would have gone through to the medical unit and the result would have been senior oversight and a strong likelihood that James would have received IV antibiotics and survived. 2
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, 2023-0376
- Added to Minute Book
- 8 Oct 2026
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- We show short extracts and link to the original. We don’t host the full report.
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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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