Anastasia Uglow
PFD Report
All Responded
Ref: 2021-0216
All 1 response received
· Deadline: 23 Aug 2021
Coroner's Concerns (AI summary)
There is a critical need to raise sepsis awareness across all schools, as healthy teenagers can rapidly deteriorate, leading to tragic consequences if the condition is left untreated.
View full coroner's concerns
Website WWW.avon-coroner.com The Coroner'$ Court; Old Weston Road, Flax Bourton, BS48 1UL May and May my
Tn this case it became clear that Ana'$ school is already taking the step to include within their first aid training for staff sepsis awareness. This case clearly demonstrates how awful this condition is and how tragic the consequences are if it left untreated_ My report is therefore written to consider raising sepsis awareness within all schools_ At the conclusion of the inquest I requested that Ana's school provide any additional information which may assist with this and they have emailed the following "Iwonder if you would be kind enough to pass this email to H M Senior Coroner. It is response to her request that BGS (Bristol Grammar School) assist in relation to her proposed PFD report to raise awareness of sepsis in schools. We respectfully submit that the Coroner should write to the Secretary of State for Education and ask him to draw the attention of the DfE Health and Safety team to her proposed PFD report: The ability of a healthy teenager to compensate for sepsis symptoms is frightening and BGS is determined to do all it can to raise awareness of this issue with the aim of preventing any future tragedies Andrew Dimberline has secured the agreement of the Outdoor Education Advisers' Panel (OEAP) and the UK Sepsis Trust that they will produce a guidance document on SEPSIS awareness and add this to the OEAP National Guidance website (https /Loeapng infoL) (the Headmaster of BGS) and (BGS staff first aid trainer) are currently liaising with the UK Sepsis trust Jof the Sepsis Trust and Dr have met recently and discussed the nature of this guidance and have also suggested that in addition to written guidance they will produce a short video for use in training School staff there will be a link to this in the OEAP guidance document BGS will fund the production of this guidance by donation to the UK Sepsis Trust and the ongoing cost of keeping it updated through an annual contribution to the OEAP. The OEAP guidance document will be produced and available to Schools for the start of the Autumn Term 2021. We are looking to launch the guidance to coincide with World Sepsis on 12 Sept 2021 in order to the maximum publicity. We would hope that the OEAP guidance document will then be something the DfE and other organisations could then to 'signpost to' in their own advice, DfE Health and safety Guidance for School visits currently signposts to OEAP Guidance in general see point 8 in https LLWWW gOV uklgovernment/publications/health-and-safety-on-educational-visits/health-and-safety-on-educational-visits OEAP guidance is also endorsed by the HSE (see https:]Loeapng infolendorsementsL) BGS will promote the guidance document to Independent School organisations HMC; GDST, ISBA. The OEAP will promote the new guidance to all Schools through its twitter and facebook accounts and the network of advisers to maintained schools and the UK Sepsis Trust will promote it through a campaign: Website WWWavon-coroner.com Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL and day gain ISC, The
Tn this case it became clear that Ana'$ school is already taking the step to include within their first aid training for staff sepsis awareness. This case clearly demonstrates how awful this condition is and how tragic the consequences are if it left untreated_ My report is therefore written to consider raising sepsis awareness within all schools_ At the conclusion of the inquest I requested that Ana's school provide any additional information which may assist with this and they have emailed the following "Iwonder if you would be kind enough to pass this email to H M Senior Coroner. It is response to her request that BGS (Bristol Grammar School) assist in relation to her proposed PFD report to raise awareness of sepsis in schools. We respectfully submit that the Coroner should write to the Secretary of State for Education and ask him to draw the attention of the DfE Health and Safety team to her proposed PFD report: The ability of a healthy teenager to compensate for sepsis symptoms is frightening and BGS is determined to do all it can to raise awareness of this issue with the aim of preventing any future tragedies Andrew Dimberline has secured the agreement of the Outdoor Education Advisers' Panel (OEAP) and the UK Sepsis Trust that they will produce a guidance document on SEPSIS awareness and add this to the OEAP National Guidance website (https /Loeapng infoL) (the Headmaster of BGS) and (BGS staff first aid trainer) are currently liaising with the UK Sepsis trust Jof the Sepsis Trust and Dr have met recently and discussed the nature of this guidance and have also suggested that in addition to written guidance they will produce a short video for use in training School staff there will be a link to this in the OEAP guidance document BGS will fund the production of this guidance by donation to the UK Sepsis Trust and the ongoing cost of keeping it updated through an annual contribution to the OEAP. The OEAP guidance document will be produced and available to Schools for the start of the Autumn Term 2021. We are looking to launch the guidance to coincide with World Sepsis on 12 Sept 2021 in order to the maximum publicity. We would hope that the OEAP guidance document will then be something the DfE and other organisations could then to 'signpost to' in their own advice, DfE Health and safety Guidance for School visits currently signposts to OEAP Guidance in general see point 8 in https LLWWW gOV uklgovernment/publications/health-and-safety-on-educational-visits/health-and-safety-on-educational-visits OEAP guidance is also endorsed by the HSE (see https:]Loeapng infolendorsementsL) BGS will promote the guidance document to Independent School organisations HMC; GDST, ISBA. The OEAP will promote the new guidance to all Schools through its twitter and facebook accounts and the network of advisers to maintained schools and the UK Sepsis Trust will promote it through a campaign: Website WWWavon-coroner.com Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL and day gain ISC, The
Responses
Action Planned
The Department for Education noted the recommendations and is making progress by working with the Outdoor Education Advisers' Panel (OEAP) and the UK Sepsis Trust to update national guidance in relation to sepsis awareness, and intends to update its Health and safety responsibilities and duties for schools to reference the work of the OEAP. (AI summary)
The Department for Education noted the recommendations and is making progress by working with the Outdoor Education Advisers' Panel (OEAP) and the UK Sepsis Trust to update national guidance in relation to sepsis awareness, and intends to update its Health and safety responsibilities and duties for schools to reference the work of the OEAP. (AI summary)
View full response
Rt Hon Gavin Williamson CBE MP Secretary of State Sanctuary Buildings Great Smith Street Westminster London SWlP 3BT
M.E. Voisin Her Majesty's Senior Coroner Area of Avon Coroner's Court Old Weston Road Flax Bourton, Bristol, 8S48 1 UL
" ,.. 'l3 August 2021 Thank you for your Regulation 28 report of 20 May 2021 following the conclusion of the inquest into the tragic death of Anastasia Uglow, in New York, on 19 December 2019 while on an educational visit with Bristol Grammar School. I was saddened to hear about this tragic case. You highlight some extremely important issues in the report. I share the concerns you have identified, and it is vital that we take steps to help prevent future tragedies of this kind occurring. I have noted your recommendations, and I can confirm that my department is making progress in the areas your report highlights. As you know the Outdoor Education Advisers' Panel (OEAP) is working with the school and the UK Sepsis Trust to update its national guidance in relation to sepsis awareness. My department responsibilities and duties for schools to reference the work of the OEAP. Outdoor learning and educational visits play an important part in the development of our young people and our guidance stresses how important it is that schools and colleges undertake a thorough risk assessment when planning such activities. intends to update its Health and safety:
I hope that the steps we are taking as set out here help to reassure you that we are not complacent about the risks associated with any educational visit. As you can see, we continue to work with sector professionals to ensure we can learn from this tragic incident and that safety is improved for all, while children are still able to enjoy exciting educational experiences that broaden their horizons. Thank you for writing on this important matter. Th Rt Hon Gavin Williamson CBE MP Secretary of State for Education /
M.E. Voisin Her Majesty's Senior Coroner Area of Avon Coroner's Court Old Weston Road Flax Bourton, Bristol, 8S48 1 UL
" ,.. 'l3 August 2021 Thank you for your Regulation 28 report of 20 May 2021 following the conclusion of the inquest into the tragic death of Anastasia Uglow, in New York, on 19 December 2019 while on an educational visit with Bristol Grammar School. I was saddened to hear about this tragic case. You highlight some extremely important issues in the report. I share the concerns you have identified, and it is vital that we take steps to help prevent future tragedies of this kind occurring. I have noted your recommendations, and I can confirm that my department is making progress in the areas your report highlights. As you know the Outdoor Education Advisers' Panel (OEAP) is working with the school and the UK Sepsis Trust to update its national guidance in relation to sepsis awareness. My department responsibilities and duties for schools to reference the work of the OEAP. Outdoor learning and educational visits play an important part in the development of our young people and our guidance stresses how important it is that schools and colleges undertake a thorough risk assessment when planning such activities. intends to update its Health and safety:
I hope that the steps we are taking as set out here help to reassure you that we are not complacent about the risks associated with any educational visit. As you can see, we continue to work with sector professionals to ensure we can learn from this tragic incident and that safety is improved for all, while children are still able to enjoy exciting educational experiences that broaden their horizons. Thank you for writing on this important matter. Th Rt Hon Gavin Williamson CBE MP Secretary of State for Education /
Sent To
- Department for Education
Response Status
Linked responses
1 of 1
56-Day Deadline
23 Aug 2021
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 20/05/2020 commenced an investigation into the death of Anastasia Ekaterina UGLOW: The investigation concluded at the end of the inquest 14th 2021. The conclusion of the inquest was Anastasia Uglow died on 19th December 2019 at Mount Sinai Hospital, New York: She was in New York on a school trip from her home in Bristol. She had been unwell in the days leading up to the trip, but became worse as the days progressed. She had influenza with pneumonia and group A streptococcus. On 18th December 2019 she participated in the trip in the morning, went shopping in the afternoon and went on a trip to the Empire State Building in the evening: On 19"h December 2019 in the morning she woke in septic shock; she collapsed in cardiac arrest; the emergency services were called but she died when she arrived at the hospital.
Circumstances of the Death
Ana had been unwell before her trip with the school but it was when she was on the trip in New York when she became more unwell: To those around her she had cold/flu like symptoms. It was reported that she told the teachers on the trip about not feeling well: She had sepsis, deteriorated and collapsed in her hotel room.
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action
Copies Sent To
coroner.com The Coroner'$ Court, Old Weston Road, Bourton, BS48 1UL may Flax
Similar PFD Reports
Reports sharing organisations, categories, or themes
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Improve Vaccine Uptake Monitoring and Evaluation
COVID-19 Inquiry
Poor prevention and early intervention
Monitor Brook House contract performance robustly
Brook House Inquiry
Poor prevention and early intervention
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.