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Another tragic death of a child from sepsis due to NHS failures


    Kerstin Kubiak, Clinical Negligence Solicitor, considers reports of the investigation by NHS England into the tragic death of a 1 year old child from sepsis and the series of failures in his care which led to his death.

    By Kerstin Kubiak

An inquest into the death of a one year old baby, William Mead, was heard in June 2015 by a Coroner in Cornwall. This was followed by a report by NHS England, which investigated the death and summarised its conclusions of failures by the NHS staff, notably the NHS Direct (111) helpline, involved in his care prior to his death in December 2014 from undiagnosed sepsis.

The death of baby William from undiagnosed pneumonia and sepsis has, in particular, raised significant questions as to whether the NHS’ out of hours helpline (111) is able to properly identify serious illness in children, so that parents can be properly advised to seek emergency care.

This sadly has striking similarities to the death of Sam Moorish, who also died of sepsis subsequent to pneumonia when a nurse on the 111 helpline failed to advise his mother to take him to A&E – see my separate article which goes into the detail of Sam’s case.  Both cases also involved failures by the out of hours GP service and a general lack of awareness of the signs and symptoms of sepsis.

Summary of circumstances:

The full report into the death of William is yet to be formally published, but it is understood to note that baby William died due to failures on the part of GPs and the NHS helpline involved in his care. He was seen on numerous occasions in the months leading up to his death, but the GPs involved failed to realise that he was suffering from pneumonia, which was worsening. When William became very ill his mother contacted the NHS helpline 111 but was advised: “…we were told William’s condition was non-urgent and didn’t require any emergency treatment, and that we would get a call-back within six hours…. But when the doctor called back after three hours, I think William’s fate was sealed. He died within 12 hours of that phone call.”

The Coroner’s Court:

At the Coroner’s Inquest evidence was heard from Professor Flemming, an eminent paediatrician from Bristol Children’s Hospital. He commented that William’s condition had been preventable but that there had been failures in reacting to his temperature, which had hit 40 degrees on 12 December.

He commented: “One of the difficulties that 111 faces is that they are not talking to a skilled professional- they are working from a script, not their professional knowledge.” He echoed the findings of the report into the death of Sam Morrish, that the ‘algorithm’ used by the 111 service did not assess the situation effectively.

Summary of report’s key findings and recommendations:

  • There was a failure by the GP to record all relevant information in the medical records
  • The symptoms should have raised a warning that there was something seriously wrong with William
  • The advice to the parents had been inadequate
  • There was no access to health records between the different NHS agencies involved, resulting in poor continuity of care
  • The computer tool used by NHS 111 was inadequate in picking up the red flag warning signs of sepsis
  • In particular there was a need for NHS call centre staff to think beyond the questions and probe further when required, in particular to see the picture of a child’s condition worsening over time


Director of nursing with NHS England in the south west, Lindsey Scott, told the BBC: “One of the significant learning points for us is how difficult it is for both professionals and parents to diagnose septicaemia. Everyone involved in this report is determined to make sure lessons are learned from William’s death, so other families don’t have to do through the same trauma.”

Very sadly this was another totally lost opportunity to save the life of a young child. Parents place their faith in the hands of medical professionals to advise them whether or not their child may be critically ill and in need of urgent medical attention. Despite further training and awareness raising within the NHS of this huge killer, sepsis, there are still patients falling through the system and this cannot continue.

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