Detection of Serious Illness in Infants and Young Children Remains a Key Risk in NHS

Priscilla Lynch 

December 13, 2021

Recognising serious illness in infants and young children remains a key patient safety risk across the NHS, according to a new report from the Health Safety Investigation Branch (HSIB).

The UK has one of the highest childhood death rates in Europe, and infections remain the leading cause of death in children under the age of 5.

However, it is especially difficult to distinguish between simple viral illnesses and life-threatening bacterial infections in very young patients, the HSIB noted in its investigation report, which was triggered by the death of a young child who died after a failure to diagnose and treat their acute infection in time. The 3-month-old infant was admitted to a hospital and discharged 4 hours later. The infant was re-admitted less than 4 hours later and died of meningococcal disease  (serogroup B).

The HSIB’s subsequent investigation focused on understanding and describing circumstances in which the acutely ill infant is not recognised and/or acted upon. This involved a review of healthcare staff training and preparedness for recognising and responding to sick infants. The investigation also explored how clinical information is communicated along with the transfer of information between people, including parent/carer input and handover of information between health care staff. 

HSIB Recommendations

The final report from the HSIB makes the five following safety recommendations:

System-wide Paediatric Observation Tracking (SPOT)

HSIB recommends that the Chair of the NHS System-wide Paediatric Observations Tracking (SPOT) Programme ensures that the Association of Ambulance Chief Executives, community NHS 111 providers, and primary care services are integral members of the NHS SPOT Programme.


HSIB recommends that NHSX develops national standards describing the electronic deployment of the NHS System-wide Paediatric Observations Tracking (SPOT) e-PEWS (the digital version of the Paediatric Early Warning Score tool), in collaboration with the NHS England and NHS Improvement SPOT programme. This should include specifications for data capture, calculation of the score, and escalation status, as well as display of the information and connectivity with other digital systems.

System-wide Paediatric Observation Tracking (SPOT)

HSIB recommends that the Chair of the NHS SPOT programme ensures that any resources produced include examples of children and young people with non-white skin showing signs of serious illness.

Association of Ambulance Chief Executives

HSIB recommends that the Association of Ambulance Chief Executives works together with the ambulance services to share best practice in relation to paediatric training, education resources, frequency, and types of training, and that it collates and shares areas of best practice.

College of Paramedics

HSIB recommends that the College of Paramedics works with partners and higher education providers to develop, agree, and implement standards for paediatric education for the future ambulance service workforce.

Previous HSIB Report Related to Health Care for Children

Earlier this year, the HSIB released a report on shortcomings in diagnosing and managing chronic childhood asthma. Outcomes for children and young people with asthma in the UK continue to be amongst the worst in the developed world and are twice as bad as the next worst country in Europe

The HSIB’s report noted there are three deaths daily in the UK associated with asthma, and that chronic asthma in children under 16 is inadequately recognised and managed. It made seven recommendations related to improving asthma care for children.


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