A woman comforting another woman.

Report highlights impact of delays in recognising acutely unwell infants

by Communications team

Recognising serious illness in infants and young children remains a key patient safety risk across the NHS, says our latest report.

Despite advances in treatments, infections remain the leading cause of death in children under the age of five.

Our national investigation emphasises that infants and children who have a fever without apparent cause are of particular concern because it is difficult for healthcare professionals to distinguish between simple viral illnesses and life-threatening bacterial infections. This was highlighted in the case that underpinned our national investigation in which Mohammad, a three-month old baby, sadly died from septicaemia caused by meningococcus (serogroup B) bacteria.

On the day before he died, Mohammad had been unsettled and was taken to hospital by ambulance on the advice of NHS 111. He had been exhibiting symptoms of vomiting, his heart rate and breathing rate were higher than the expected range, he had a higher than expected temperature and he had an episode of grunting with pale/blue skin after vomiting.

He was admitted but discharged after four hours as it was felt that he was suffering from a mild viral illness rather than sepsis. Another ambulance was dispatched less than four hours later on the advice of the hospital after his mother had phoned the ward to say he had developed a red blister rash. He was taken back to hospital but not under a ‘blue light’ emergency transfer. Within an hour of being admitted, Mohammad suffered a respiratory and then cardiac arrest. Staff attempted to resuscitate him for 42 minutes but weren’t able to save him.

The diagnostic challenges seen in Mohammad’s case are well known across the NHS and evidenced by national research which highlights that the recognition of acutely unwell infants and children is complex and also that they can deteriorate rapidly from what appear to be mild symptoms.

Research cited in the report also emphasises that there is no consistent validated tool for identifying sepsis or risk of sepsis. While Paediatric Early Warning Scores (PEWS) are widely used internationally, evidence revealed a lack of consensus on which PEWS system is most effective or useful.

Our in-depth investigation identified further findings, highlighting the factors that contribute to deterioration in children being missed.

  • Communication and sharing information with parents/carers – the investigation found that parents often describe feeling ‘powerless’ when describing concerns and that healthcare professionals don’t listen to what they are telling them. HSIB also emphasises that safety advice on deterioration to parents varies across the NHS. The subject of recognising and acting on the concerns of parents and healthcare professionals about a child is also being incorporated into PEWS systems.
  • Impact of demands on resources in ED’s treating children – HSIB identified that staffing standards can’t always be met in busy environments, particularly in hospitals without a dedicated paediatric ED.
  • Wider involvement from across the NHS to develop early warning tools – the investigation highlighted that the Association of Ambulance Chief Executives (AACE) are not currently involved in the ongoing national work to develop early warning scores for infants and children.
  • The use of skin colour as a parameter to assess acutely unwell infants and children – HSIB identified that existing systems for triage do not always take into account the colour of a patient’s skin and that it is harder to spot some signs such as skin turning blue in non-white skin.
  • Pre-hospital care and spotting the signs of an acutely unwell child - the investigation identified a gap in training at undergraduate paramedic level and then in the initial and continuing paediatric training for ambulance staff.

The report concludes with five safety recommendations focused on improving the recognition and assessment of infants and children who are seriously unwell. The recommendations highlight the importance of an appropriate paediatric early warning scoring (PEWS) system, together with the ability to reference and share this information across all health services.

Recognising and acting on the concerns of parents and healthcare professionals about a child has been emphasised in training and is also being incorporated into the national PEWS systems. The recommendations include improved paediatric training for ambulance personnel and paramedics.

Nichola Crust, National Investigator, HSIB

“Mohammad’s case shows just how devastating a delay in recognising a seriously ill child can be. It also reinforced how quickly a young child or infant can deteriorate. Throughout our investigation, we saw that distinguishing between a mild illness and serious infection continues to present a challenge for NHS staff especially as ED’s and paediatric wards are stretched beyond capacity. Healthcare staff are the most important resource in these circumstances and there need to be sufficient numbers throughout the urgent and emergency care pathway, with the right training and clinical experience and seniority, to safely deliver the right standard of care to patients. The investigation also emphasises that this is exacerbated with the varied use of paediatric early warning scores, with many systems not sensitive or specific enough to detect deterioration.

“Serious illnesses like meningitis and sepsis can be treated successfully if caught in time, and the aim of our investigation was to identify what could cause a delay in recognition, and what improvements could be made at a system level to tackle this significant risk. This is a safety issue that seen across many areas in the NHS and our recommendations and observations have been developed to aid those seeing and caring for children and providing advice to parents in quickly identifying a seriously ill child or infant. This will help them to receive rapid treatment, reducing the risk of severe harm and preventing families from suffering the heartbreaking loss of a child.”

Dr Damian Roland, Consultant and Honorary Associate Professor in Paediatric Emergency Medicine

“The death of any child is a tragedy, particularly if in different circumstances that life may have been saved should different actions been taken. This is an important HSIB report as it highlights the system risks that exist in acute care pathways for children. Healthcare staff often work in challenging situations in which skill mix and staffing number do not meet demand. This exacerbates known issues of healthcare professionals communication with families, and between themselves, when identifying and describing children at risk of deterioration. This report highlights the importance of the ongoing work on developing a standardised in-patient early warning score and how this fits into the system wide paediatric observation tracking (SPOT) programme.

Professor Sarah Neill, Professor of Nursing

“Recognising acute illness in infants and young children is difficult for parents and health professionals. Diligent investigations, such as this from HSIB, enable us all to learn from the tragic loss of a child when that illness isn’t recognised. Losing your child, when the death might have been preventable, is the hardest thing any parent can imagine. Such a loss would be so much worse should no learning come from it. This report has identified key areas for health services, health professionals and future research including the imperative to listen to parents concerns and the need for further research to explore how parent’s voices can contribute to recognition of the sick child. A related observation, within the report, is the need to review educational resources for parents caring for young children to identify how they need to work so that they inform and empower parents seeking help for an acutely ill child.”

Safety recommendations

  • The Chair of the NHS System-wide Paediatric Observations Tracking (SPOT) Programme ensures that the Association of Ambulance Chief Executives, community NHS 111 providers and primary care services are integral members of the NHS SPOT Programme.
  • NHSX develops national standards describing the electronic deployment of the NHS System-wide Paediatric Observations Tracking (SPOT) e-PEWS (the digital version of the Paediatric Early Warning Score tool), in collaboration with the NHS England and NHS Improvement SPOT Programme. This should include specifications for data capture, calculation of the score and escalation status, and also the display of the information and connectivity with other digital systems.
  • The Chair of the NHS System-wide Paediatric Observations Tracking (SPOT) Programme ensures that any resources produced include examples of children and young people with non-white skin showing signs of serious illness
  • The Association of Ambulance Chief Executives works together with the ambulance services to share best practice in relation to paediatric training, education resources, frequency and types of training, and that it collates and shares areas of best practice.
  • The College of Paramedics works with partners and higher education providers to develop, agree and implement standards for paediatric education for the future ambulance service workforce.

Notes to Editors

  • Meningococcal disease is the term used for infections caused by the bacterium meningococcus.
  • Meningococcal infection can cause meningitis and meningococcal septicaemia (infection of the bloodstream). Both of these diseases can lead to meningococcal sepsis, a reaction to infection that causes a person’s body to damage its own tissue and organs.
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