Alaanuloluwa Joseph

PFD Report Historic (No Identified Response) Ref: 2017-0189
Date of Report 14 June 2017
Coroner Sean Cummings
Coroner Area London (West)
Response Deadline est. 4 October 2017
Coroner's Concerns (AI summary)
Inaccurate monitoring and recording of fluid intake and output, a critical aspect of sepsis management, was not undertaken.
View full coroner's concerns
Evidence was heard that indicated that accurate monitoring and recording of fluid intake and output was not undertaken_ Evidence was also heard that fluid management in sepsis is of critical importance_
Sent To
  • Hillingdon Hospitals NHS Trust Hillingdon Hospital
Response Status
Linked responses 0 of 1
56-Day Deadline 4 Oct 2017
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
Inquest into the death of Alaanuloluwa Joseph
Circumstances of the Death
Master Alaanuloluwa Joseph died from sepsis, lung abscess and bacterial pneumonia at Great Ormond Street Hospital on the 22nd December 2015. He had been admitted to the Hillingdon Hospital during the early hours of the same day:
Action Should Be Taken
To review the management of sick children in the Paediatric Accident and Emergency Department to ensure that all those suspected of having infection or sepsis must have fluid balance charts completed.
Related Inquiry Recommendations

Public inquiry recommendations addressing similar themes

CDI patient observations records
Vale of Leven Inquiry
Missed and inaccurate patient observations Inaccurate and inaccessible patient records
Healthcare trust risk information visibility
Southport Inquiry
Inaccurate and inaccessible patient records
Data Systems for High-Risk Individuals
COVID-19 Inquiry
Inaccurate and inaccessible patient records
Patient Records Audit
Infected Blood Inquiry
Inaccurate and inaccessible patient records
Blood Test Result Documentation
Hyponatraemia Inquiry
Inaccurate and inaccessible patient records
Recording Clinical Discussions
Hyponatraemia Inquiry
Inaccurate and inaccessible patient records
Improve perinatal mortality recording
Morecambe Bay Investigation
Inaccurate and inaccessible patient records
Detainee Capture and Condition Records
Al-Sweady Inquiry
Inaccurate and inaccessible patient records
Medical Fitness for Detention Forms
Al-Sweady Inquiry
Inaccurate and inaccessible patient records
CDI patient information
Vale of Leven Inquiry
Inaccurate and inaccessible patient records

Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.