Response to HSIB investigation: Recognition of the acutely ill infant


  • 9th December 2021

Today the Healthcare Safety Investigation Branch (HSIB) has released a new report aimed at helping to improve patient safety in relation to recognition of the acutely ill infant and child.[1]

The investigation reviewed the case of Mohammad, a baby who had become unwell and was taken to an emergency department by ambulance following a call to NHS 111. He arrived at 8.04pm and was considered to have a mild viral illness, subsequently being transferred to a paediatric observational ward, and discharged at 11.45pm with a diagnosis of likely bronchiolitis.

At approximately 3.40am his mother contacted the ward as his condition worsened, which resulted in a 999 call. The ambulance crew did not consider that Mohammad was seriously ill so did not conduct a ‘blue light’ emergency transfer to hospital. Mohammad was admitted to the emergency department at approximately 4.40am and suffered a respiratory and then cardiac arrest at 5:28am, with attempts to resuscitate unsuccessful and stopped at 6:10am. Mohammad died of septicaemia caused by meningococcus (serogroup B) bacteria.

Patient Safety Learning welcomes the publication of this new report by HSIB looking at ways to improve patient safety in relation to recognition of the acutely ill infant and child. Our reflections on this report are as follows:

Increased collaboration within the NHS SPOT Programme

We welcome HSIB’s recommendation that the NHS SPOT Programme should ensure it includes involvement from the Association of Ambulance Chief Executives, community NHS 111 providers and primary care services. The tragic circumstances of Mohammad’s death clearly emphasise the important role that each of these different services can play in the process of recognising life-threatening bacterial infections in very young patients.

Health inequalities

This investigation specifically draws attention to existing systems for triage in primary and secondary care not always considering the colour of a young patient’s skin, noting the impact this may have on a healthcare professionals’ assessment of physical signs. The report indicates that the importance of considering how symptoms and signs can present differently on dark skin has been highlighted in Mind the Gap: A handbook of clinical signs in Black and Brown skin.[2] They also refer the ongoing work of the Skin Deep Project, which aims to develop a free, open-access bank of high-quality photographs of medical conditions in a range of skin tones for use by both healthcare professionals and the public.[3]

We welcome HSIB’s specific recommendation that the SPOT programme should seek to ensure its resources include examples of children and young people with non-white skin showing signs of serious illness. We know however that safety issues faced by patients due to the colour of their skin are not limited to these specific cases.[4]

In line with the ambition set out in the NHS Long Term Plan to take a more concerted and systematic approach to “reducing health inequalities and addressing unwarranted variation in care”, we believe this should be a priority issue for the NHS National Patient Safety Team.[5] We would like to see them working together with the Dr Bola Owolabi, Director – Health Inequalities at NHS England and NHS Improvement, to scope a potential programme of work in this area.

Listening to parents

The report highlights the in this case concerns about communications Mohammad’s parents, noting “the family’s perception is that they trusted what staff were telling them but that they were ultimately not listened to”. This remains a recurring problem in healthcare and emerges time and again in patient safety failings. Too often concerns raised by patients and family members are not acted on and, when harm occurs, they are left out of the investigation process.

In our report, A Blueprint for Action, we set out what we believe is needed to progress towards a patient-safe future, identifying six foundations of safe care. Patient engagement is one of those six foundations. In this we outline how patients should be engaged for safety at the point of care, if things go wrong, in improving services, advocating for changes and in holding the system to account.

The value of early warning scores

The report highlights that research which shows that existing early warning scores are not sensitive or specific enough to help health professionals to distinguish between a seriously unwell infant/child and one with a mild viral illness. It states that “changes in vital signs (for example temperature, heart rate and respiratory rate) may be predictors of deterioration in an infant or child but they may also simply reflect that a child is unwell but not at significant risk”.

We find it surprising therefore that there is not a reflection or recommendation on the need to support clinicians in their assessment of deteriorating patients, such as the further development of early warning scores.

Review of ambulance service training

The report notes the following safety observation:

“It may be beneficial if the 10 English ambulance services review and assess their paediatric training provision and report this assessment to their trust board.”

HSIB explains this observation is intended to “identify all clinical staff working in the ambulance service that have accessed ‘Spotting the sick child’ or equivalent training as an education resource and find out how often it has been accessed, and to highlight any gaps in training needs for recognition of the acutely ill infant/child”.

It is our view that it would be preferable for this to be a specifically cited safety recommendation for implementation and response.


[1] HSIB, Recognition of the acutely ill infant, 9 December 2021.

[2] M. Mukwende, P. Tamonv, M. Turner, Mind the Gap: A handbook of clinical signs in Black and Brown skin, September 2020.

[3] Skin Deep: A DFTB Project, About Us, Last Accessed 9 December 2021.

[4] Rebecca Tatum, ‘Mistreatment’ due to the colour of your skin, Patient Safety Learning’s the hub, 12 August 2021.

[5] NHS England and NHS Improvement, The NHS Long Term Plan, 7 January 2019.

HSIB Report


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