“Following Iona’s death, the Northampton General Hospital NHS Trust conducted a Serious…”

The coroner’s concerns

– Following Iona’s death, the Northampton General Hospital NHS Trust conducted a Serious Incident Investigation. One of the recommendations made by the investigation panel was: “Children with pneumonia who are not improving after forty-eight hours of treatment or deteriorate at a later point should be suspected of having a pleural effusion and should get an immediate x-ray and chest ultrasound” That recommendation reflected advice provided on 29th November 2022 (the day after Iona’s admission to Northampton General Hospital) by the East Midlands Paediatric Critical Care Network: “We would like to inform you of a high number of cases of highly aggressive sepsis, linked to empyema, and positive culture for Group A Streptococcus in the region. This has caused significant morbidity and mortality. We advise early referral, aggressive management, high dose intravenous antibiotics, and early drainage of empyemas. Please have a low threshold for investigating any child with a secondary respiratory deterioration, especially with new onset of fever. Chest X-Ray and ultrasound will be beneficial.” At the inquest into Iona’s death, I heard evidence from the Trust’s Clinical Director of the Child Health Directorate who is also a Consultant Paediatrician. On the basis of the evidence I heard from the Clinical Director, I am satisfied that the Trust has taken action in respect of the recommendations made and more broadly have reflected upon the circumstances of Iona’s death. However, in respect of the recommendation set out above, I am concerned that there remains a risk that future deaths could occur unless further action is taken. The recommendation made by the investigation panel was that children with pneumonia who are not improving after forty-eight hours of treatment or deteriorate at a later point should get “an immediate x-ray and chest ultrasound”. However, the evidence I heard suggests this is not possible. I heard from the Clinical Director that as a district general hospital, Northampton General Hospital does not have access to a paediatric radiologist outside of 9am-5pm on Mondays and Fridays when such a specialist is either on duty or on-call. I heard evidence that in Iona’s case, a Consultant in ITU and Anaesthesia was able to perform an ultrasound scan at around 2pm on 4th December 2022 however this is not a facility that would routinely be available to the Trust and was not, in any event, part of that clinician’s core duties. I am concerned that a very unwell child who may require a chest ultrasound may not receive one ‘immediately’ and in fact may have to wait for a considerable period of time. For example, if the need arose over a weekend, that child may not receive an ultrasound scan for up to 48 hours. 2 I understand a reason why Northampton General Hospital does not have access to a paediatric radiologist outside of 9am-5pm on Mondays and Fridays may be due to the funding that is available. I am therefore sending this letter to the NHS Northamptonshire Integrated Care Board and to NHS England.

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, 2024-0023

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