Liam Oldsworth
PFD Report
Historic (No Identified Response)
Ref: 2017-0301
Coroner's Concerns (AI summary)
The serious incident analysis report was significantly delayed in being received by the coroner's office, hindering timely review and learning.
View full coroner's concerns
_ The Serious Incident Analysis report dated 18/3/2015 has only within the last week been received by this office_ Attached are recommendations and shared learning:
Sent To
- United Lincolnshire Hospital
Response Status
Linked responses
0 of 1
56-Day Deadline
23 Jan 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 19/08/2014 commenced an investigation into the death of Liam Oldsworth, aged 22 Months. The investigation is currently on going: At post mortem the medical cause of death was reported as 1a Aspiration Pneumonia Long standing Hypoxic Ischaemic Brain Injury and West Syndrome_
Circumstances of the Death
The child was bought into the Pilgrim Hospital, Fishtoft; Boston with a high temperature, 41.9 and difficulty in breathing: No infection found. Patient treated for Septicaemia and meningitis with antibiotics, condition deteriorated despite all medical support
Action Should Be Taken
In my opinion bearing in mind this report is now over 2 years old but was only delivered to this office in the last week all these recommendations should now have been acted upon and implemented and if not why not and timescale for compliance. Please confirm_
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No open learning culture
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.