Child Death

Action Planned (AI summary) NICE acknowledges the difficulty of recognising sepsis in children and highlights existing guidance and screening tools. They are planning to update their guidance on paediatric sepsis in 2026, considering adapting the current 'traffic light' system to one based on NPEWS.

Action Planned (AI summary) Royal Cornwall Hospital is changing their language in the Emergency Department when asking parents about how babies are fed from ‘bottle’ to ‘formula’ and this will be reflected in ED documentation. Maternity services use routine enquiry about the exact nature of bottle feeding as a mandatory question at every safe opportunity and have an Enhanced Continuity Pathway developed and implemented along with pregnancy circles with face-to-face translators. Cornwall Council has secured funding to rewrite/update the ‘Essential Guide to feeding and caring for your baby’, deliver a mandatory webinar on language/terminology and safe formula guidance by the end of January 2026, finalise and publish Interpretation SOP and add targeted checks on recording "what’s in the bottle". Cornwall Partnership NHS Foundation Trust has instructed Minor Injuries Unit staff to ask for specific details if there are any concerns about a child’s nutrition including what is being fed. Staff have also been reminded that children attending the MIU should be weighed on each visit, and for those aged 2 and under, this should also be recorded in the child’s red book.

Action Planned (AI summary) Barts Health NHS Trust's Haemoglobinopathy Coordinating Centre (HCC) is developing a website with information to support families and has appointed a governance lead to lead on network wide quality improvement and governance. They are also involved in an exhibition to challenge staff attitudes and behaviours towards patients. Maylands Healthcare has undertaken an annual audit of patients with Sickle Cell Disease, proactively contacts them for medication reviews, liaises with specialists, changes medications to electronic repeat dispensing, and shares learning points from Significant Event Analyses with staff. They have also added clear alerts in each clinical record and all clinical staff have undertaken mandatory Sepsis training. The Department of Health and Social Care has introduced an incentive for GPs to identify patients who would benefit most from continuity of care, and has implemented "Jess's Rule", encouraging clinicians to re-evaluate symptoms if a patient's condition remains unresolved after three consultations. NHS England is also working to improve education and awareness of sickle cell disease amongst healthcare staff and for patients and carers. Partnership of East London Co-operatives (PELC) has shared organisational learning regarding the importance of reviewing patient records and included this requirement in staff contracts. They are also implementing an alert within clinical records for all children presenting with sickle cell disease.