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Written on 11th January 2022 by Susan Brown

Healthcare watchdog, HSIB, has found lack of training and staff shortages, ‘white skin bias’ and failure to listen to parents’ concerns are just some of the many reasons why serious illness is not recognised in babies and children. HSIB published the results of its investigation into NHS failure to recognise when infants (babies or young children) are seriously ill, in its report, Recognition of the Acutely Ill Infant.

Is there a patient safety risk to babies and young children with serious illness?

According to HSIB, problems with timely recognition of serious (acute) illness in infants and young children is a known patient safety risk across the NHS.  Delayed diagnosis of infection is a particular cause for concern as untreated infection can lead to life-threatening illness or severe disability from meningitis or sepsis. The most common sign of infection is a high temperature or fever. Feverish illness affects up to 40% of young children each year. Fever is the most common reason for taking a child to the doctor and the second most common cause of children’s hospital admissions. Infection is the leading cause of death in children under the age of five.

Serious illness from infection, such as meningitis and sepsis, can be treated successfully if it is caught in time. This depends on prompt recognition, diagnosis and treatment because the disease develops rapidly in these serious conditions. Recognition of seriously unwell infants is more complex than in adults, and apparently mild symptoms can deteriorate very rapidly. HSIB found that infants who have a high temperature without an obvious cause are at greater risk because healthcare staff often cannot tell the difference between simple viral illnesses and life-threatening bacterial infections. HSIB say that research has shown that a significant proportion of child deaths could have been avoided if they had been treated correctly at their first contact with the NHS, and children have died because the severity of their illness was not recognised at an early stage.

The danger to infants is recognised in guidance by the RCEM (Royal College of Emergency Medicine) and the RCPCH (Royal College of Paediatrics and Child Health) which emphasise the importance of prompt review by a suitably experienced clinician (such as a doctor). Children with abnormal vital signs at initial assessment must be reviewed within an hour, or sooner (according to the RCEM) in the case of serious conditions.

HSIB’s investigation into recognition of the acutely ill infant

HSIB launched its national investigation to identify the causes of delayed or failed recognition of serious illness in babies and young children, so that improvements can be made to reduce the risk of severe harm to these children.  Their national investigation was triggered by an individual case relating to a three-month-old baby who died from septicaemia after hospital staff failed to recognise and treat his bacterial infection.

On the advice of NHS 111, the baby had been taken to hospital as an emergency by ambulance. His symptoms included vomiting, followed on one occasion by grunting and blue/pale skin, an abnormally high heart rate, breathing rate and temperature.  He was discharged from hospital four hours after admission on the assumption that he had a mild viral illness. Less than four hours later his mother telephoned the ward to say that he had developed a red blister rash. An ambulance brought him back to hospital but  not as a ‘blue light’ emergency, as the  ambulance crew did not consider him to be seriously ill. Within an hour of being re-admitted to hospital, he suffered a respiratory (breathing) and cardiac arrest. Staff couldn’t resuscitate him. He died of septicaemia (bacterial infection in the bloodstream) from meningococcus B.

What did HSIB’s investigation on recognition of the acutely ill infant find?

HSIB’s report set out its findings from its national investigation into the causes of delayed recognition of seriously unwell infants. Many of the factors that are known to contribute to the safety risks to acutely ill infants were also highlighted by the three-month-old baby’s tragic case.

HSIB’s findings included:

  • Meningococcal disease is a significant cause of serious illness and death in children.
  • Hospital staff can find it difficult to:
  • distinguish between infants with mild viral illnesses and those with serious bacterial infections, such as meningococcal disease;
  • identify clinical deterioration in infants and children with serious illness.
  • Paediatric Early Warning Score (PEWS) systems are widely used around the world to monitor infants’ and children’s health, but:
    • there is a lack of agreement about which system is most effective or useful;
    • there is no early warning score that will always detect deterioration in infants or children;
    • existing early warning scores are not sensitive or specific enough to help health professionals to distinguish between a seriously unwell infant and one with a mild viral illness;
    • there is no consistent validated tool for identifying (risk of) sepsis;
    • information, including trends in an infant’s PEWS, is not always available to staff when they are assessing patients;
    • the Association of Ambulance Chief Executives (AACE) are not involved in the development of early warning scores for infants and children.
  • Clinical experience and judgement are essential to detect deterioration in an infant or child whose vital signs are normal or only slightly abnormal.  
  • There are gaps and variations in student level and ongoing training for ambulance personnel, including paramedics and other clinicians, on identifying unwell infants and children.
  • Infants and young children may have high temperatures (fever) and vomiting together with irritability, drowsiness and confusion, which can be very hard to assess. Parents’ worries about their child’s alertness and responsiveness must always be taken seriously. However, despite all the research that recognises that parents know their children best and often know that that their child is unwell before the child’s vital signs become abnormal, HSIB found that:
    • parents often feel ‘powerless’ when trying to describe their concerns about their child;
    • some healthcare professionals don’t consider or listen to what parents are telling them;
    • advice given to parents on how to identify deterioration in their child after leaving NHS hospitals varies.
  • Systems for ‘triage’ (assessing a patient’s priority for treatment) often don’t take into account the colour of a patient’s skin. Factors relating to skin colour included:
    • ‘White skin bias’:
      • assessments of skin colour in which people were asked if patients are ‘pale’ or if their lips have ‘turned blue’, which is not useful for patients with non-white skin;
      • descriptions of rashes which focus on redness or paleness, which are harder to recognise in non-white skin.
    • Environmental challenges, such as poor lighting, make it harder for ambulance personnel to assess a child’s skin colour.
  • Using medicines, such as paracetamol, to bring down a child’s temperature can mask their symptoms of serious illness.  
  • A&E departments and paediatric assessment wards are very busy with increasing numbers of admissions, but the number of children with serious bacterial infection is not increasing. (Spotting the acutely unwell infant can feel like finding a needle in a haystack).
  • National standards exist for the care of children in emergency care settings, but hospitals struggle to recruit the workforce needed to comply with the staffing standards, particularly in hospitals without a dedicated paediatric emergency department. This is made worse by the current shortage of trained, competent healthcare staff and over-stretched NHS hospital resources.

HSIB made a number of safety recommendations to the NHS, which included:

  • highlighting the importance of an appropriate paediatric early warning scoring (PEWS) system, which can be shared across all health services;
  • improving paediatric (child specialist) training for ambulance personnel and paramedics;
  • ensuring that training resources include examples of signs of serious illness in children with non-white skin.

Helping infants and children with serious disability caused by delayed recognition of serious illness

Boyes Turner’s clinical negligence team have helped countless children and their families recover compensation and rebuild their lives after delayed diagnosis of neonatal, infant or childhood illness has left them with brain injury or permanent disability. We welcome HSIB’s report in the hope that the NHS can be properly supported to learn, and adequately resourced to improve the care, and reduce the harm, to seriously unwell children.

If you are caring for a child whose disability was caused by medical negligence and you would like to find out more about making a claim, you can talk to one of our solicitors, free and confidentially, by contacting us here.