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Recognition of the acutely ill infant

Summary

The national investigation

The HSIB was notified of a three-month-old infant who was admitted in to a hospital and discharged four hours later. The infant was re-admitted less than four hours later and sadly died of Meningococcus (serogroup B). HSIB has now completed an investigation regarding the recognition of the acutely ill infant.


Reference event

The HSIB was notified of a three-month-old infant who was admitted in to a hospital and discharged four hours later. The infant was re-admitted less than four hours later and sadly died of Meningococcus (serogroup B).


Investigation summary

The investigation focused on understanding and describing circumstances in which the acutely ill infant is not recognised and/or acted upon.

This involved a review of staff training and preparedness for recognising and responding to the sick infant. The investigation explored how clinical information is communicated along with the transfer of information between people. This included the voice of the parent/carer and handover of information between staff. 

The investigation considered the system and environmental influences that impact on the decision making process, taking into account the contextual factors that influence the effectiveness of existing track and trigger tools for acutely ill infants.