UK Inquiry Tracker

Alfie Scambler-Holt

PFD Report Historic (No Identified Response) Ref: 2018-0156

Date of Report 21 May 2018

Coroner Alison Mutch

Coroner Area Manchester (South)

Response Deadline est. 2 September 2018

Hospital Death (Clinical Procedures and medical management) related deaths

Judiciary.uk Report PDF

Coroner's Concerns (AI summary)

The absence of a national PEWS scoring system creates inconsistency across trusts, leading to varied escalation processes and potential risks for children transferred between hospitals.

View full coroner's concerns

In the circumstances, it is my statutory to report to you: The inquest heard that since the death of Alfie Scambler -Holt the Trust had done a significant amount of work looking at PEWS scores and escalation processes. The Clinical Lead for Paediatrics told the inquest that one of the challenges was that there was no national PEWS scoring system. As a result there were different PEWS scoring systems in operation in different trusts. This meant that dealing with children and moving/rotating between Trusts would not necessarily be dealing with the same system and escalation processes:

Sent To

NHS England
Secretary of State for Health

Response Status

Linked responses 0 of 2

56-Day Deadline 2 Sep 2018

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 5th June 2017 commenced an investigation into the death of Alfie Scambler-Holt: The investigation concluded on the 8t 2018 and the conclusion was of; Narrative: Died #S a consequence of an overwhelming infection On 9 background of ccrebral palsy. The medical cause of death was; Ia Sepsis; Ib Respiratory Tract Infection; ILI Cerebral Alfie Scambler-Holt had cerebral palsy and complex health needs as a result: On 3rd June 2017, just after 10.00, his mother went in to his bedroom and found he was very unwell: He had been well at 03.00. An ambulance was called and arrived within 10 minutes. Sepsis was suspected and he was transferred to Stepping Hill Hospital. Stepping Hill Hospital were on standby for his arrival. He was treated for suspected sepsis. His PEWS score was 8. The initial intravenous access tissued out after 5Oml of fluid had been administered. Repeated unsuccessful attempts over an hour were made to access before doctors were successful and antibiotics could be administered. He was transferred to the Paediatric Unit: His care was supervised by the registrar. He was not seen by a consultant: His PEWS score was 6 and his blood results showed high lactate and sodium levels indicating kidney compromise. He was treated with fluid boluses being administered. Fluid output levels were monitored through nappies rather than catheterisation. His PEWS score dropped to 4. His blood gas results remained high: A discussion with the on call consultant resulted to the agreement on the management plan. A consultant review in person was not carried out: At 20.00 on 3rd June 2017 his PEWS score rose to 6 and he was examined by the Registrar who prescribed a saline nebuliser in addition to the fluids prescribed. A 21.05,he suddenly stopped breathing: A prolonged attempt to resuscitate him was unsuccessful and he died at Stepping Hill Hospital on 3rd June 2018 from sepsis 11 hours after his admission. May one Palsy gain the gas

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: