Child Death

Concerns summary The current system allows inexperienced 17-year-old drivers to drive unsupervised with teenage passengers, which is a factor in collisions and increases the risk of future fatal incidents.

Concerns summary A lack of national guidelines exists for assessing paediatric heart conditions like myocarditis, coupled with insufficient awareness of Parvovirus. Locally, critical radiology reports were delayed, metabolic acidosis causes were not fully explored, and documentation of observations and handovers was incomplete.

Concerns summary A delay in obtaining adrenaline during resuscitation occurred due to non-standardised paediatric crash trolleys across hospitals, hindering junior doctors in a time-critical situation.

Concerns summary A national shortage of donor livers, particularly for "super urgent" children, is exacerbated by clinical guidance. This has led to extended waiting times, significantly increasing the risk of lives being lost due to organ unavailability.

Concerns summary NWAS failed to communicate significant ambulance delays to callers, even when a patient's condition deteriorated from Category 2 to 1. This lack of follow-up risks further deaths.

Concerns summary There is no nationally validated sepsis screening tool for Paediatric Emergency Departments, and the trust's own tool lacks consistent application between departments.

Concerns summary An unsecured ligature point was accessible, and emergency services faced difficult, treacherous access to the location, hindering timely intervention.

Concerns summary Mental health ward staff lacked neurodiversity training and were inexperienced, leading to insufficient staffing, missed patient observations, and incorrect medication charting.