Lila Marsland

Minister of State for Health (Secondary Care) 

39 Victoria Street 
London 
SW1H 0EU 

HM Area Coroner Chris Morris  
Coroner’s Court,  
1 Mount Tabor Street,  
Stockport, 
SK1 3AG 

12th September 2025 

Dear Mr Morris,  

Thank you for the Regulation 28 report of 11th June 2025 sent to the Secretary of State for 
Health and Social Care about the death of Lila Airelle Marsland. I am replying as the Minister 
with responsibility for data and technology.       

Firstly, I would like to say how saddened I was to read of the circumstances of Lila’s death, 
and I offer my sincere condolences to their family and loved ones. The circumstances your 
report describes are concerning and I am grateful to you for bringing these matters to my 
attention.  

Following the death of Lila Marsland, CQC reviewed the case through their specific incident 
process and determined it did not meet the criteria for criminal prosecution. A decision was 
made,  however,  to  assess  Children  and  Young  People’s  services  at  Tameside  General 
Hospital.  

CQC commenced a responsive assessment of Tameside General Hospital on 4 December 
2024  and  carried  out  an  unannounced  inspection  between  28  to  30  January  2025.  The 
service was rated Good overall and the assessment report, published 6 June 2025, can be 
the  CQC  website:  https://www.cqc.org.uk/location/RMP01/reports/LAP-
viewed  on 
01392/services-for-children-and-young-people 

CQC are reviewing the coroner’s findings to determine any further action and also await the 
response from the Trust to the Coroner to inform this activity. 

The  report  raises  concerns  to  the  Department  of  Health  and  Social  Care  on  information 
being  stored  and  shared  between professionals in a  fragmented and disjointed  way,  and 
that details of examinations and assessments undertaken were recorded on a mixture of 
analogue and digital systems in operation in different parts of the Trust.  

I agree that ensuring health and care professionals have access to a single source of 
digital information about the patients they are treating and caring for is vitally important to 

 
 
 
 
 
 
 
 
 
 
  
 
 
 
  
 
  
  
 
  
 delivering the best care possible. The Department of Health and Social Care, and NHS 
England have programmes of work underway which should assist in preventing future 
deaths connected to this issue.  

Since 2022, £1.9bn has been invested in laying the foundations for digital transformation 
across the health and care system, including rolling-out Electronic Patient Records to NHS 
trusts that don’t have one, and supporting those with an existing one to replace, extend or 
optimise it. Currently, 93% of Secondary Care Trusts have an EPR in place, we expect 
96% of trusts to have EPRs by March 2026, with the remainder to follow. 

NHS England is also providing support to bring trusts up to an optimum level of digital 
maturity, with all secondary care organisations completing a Digital Maturity Assessment in 
May 2024, which will be run yearly to track progress and identify areas for improvement, 
which will further reduce barriers to the sharing of information needed to treat patients. 

Going beyond this, the Government’s 10 Year Health Plan commits to delivery of a single 
patient record (SPR). This will provide a comprehensive patient record, bringing together 
all of a patient’s medical records into one place. We have been engaging with the public to 
help shape our plans, including what information they would like to see included in a single 
patient record and we will continue to talk to the public and to health and care 
professionals as we design the SPR to ensure their needs are reflected. The SPR will 
begin to go live from 2028 and be rolled out first in maternity care. 

Introducing a single patient record will give clinicians all the data they need when treating 
patients. By having access to all relevant information about a patient, frontline staff will be 
able make more informed decisions and deliver the best care at the time it is needed.  

I hope this response is helpful. Thank you for bringing these concerns to my attention.   

Yours sincerely,  

MINISTER OF STATE FOR HEALTH

Chief Executive Officer 
 Tameside and Glossop Integrated Care NHS Foundation Trust  
Silver Springs  
Fountain Street  
Ashton under Lyne  
Lancashire OL6 9RW 

11th August 2025 

FAO Mr Morris 

HM Coroner  
Coroner’s Court  
1 Mount Tabor Street  
Stockport  
Cheshire  
SK1 3AG 

Dear Mr Morris 

Reference: 

I  am  writing  further  to  the  inquest  regarding  the  death  Lila  Marsland  (who  died  on  28th 
December 2023) which concluded on 6th June 2025 and the subsequent Regulation 28 Notice 
issued to the Trust. I hope to set out below my response in terms of what we are already doing 
and what we plan to do in relation to your concerns.   

Concern 1 - notwithstanding the work the Trust has undertaken in response to Lila’s 
death, the Child Sepsis Screening Tool is not yet fully embedded in the minds of those 
who assess and treat Children and Young People at the Trust 

I would like to take you through and reinforce some of the key improvement works the Trust 
is undertaking to ensure that the Sepsis Screening Tool is fully embedded in the mind of those 
who assess and treat children and young people.  

The Trust have implemented regular audits for PEWS and sepsis. Since February 2025 this 
has converted to daily audits. The results of these audits are shared on safety huddles and 
immediate actions taken. The Paediatric ED Matron reviews the audits weekly, sends action 
emails if themes appear and if there is any individual learning identified there will be further 
training provided by the Paediatric ED Matron and the Practice Based Educators (PBE). 

The  Paediatric  Matron  has  also  devised  individual  sepsis  and  PEWs  action  plans  which 
monitor  the  calculation  of  PEWS  scores,  observations  and  escalations.  These  results  are 
shared monthly at the Sepsis and Deteriorating Patient Program Board which is chaired by 
the Deputy Medical Director. The Trust also has in place a Trust wide Sepsis Action Plan led 
by the ED Matron and ED Consultant. This Trust wide Action Plan is also discussed and has 
oversight at the monthly Sepsis and Deteriorating Patient Program Board.  

 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 From August 2025 onwards, the Trust will be incorporating audits as additional standards to 
the  Quality  Assurance  Rounds  (QAR)  conducted  each  month.  This  will  allow  for  greater 
oversight of audit results and make it easier to analyse the data. The audit outcomes will help 
identify clinical improvement opportunities and will also be used for feedback to division and 
governance meetings. The data gathered each month will be reviewed the following month. 
To support this change, the Quality and Patient Experience Team arranged a series of rollout 
education sessions for Ward Mangers and Matrons throughout July/August 2025.  

to  ED 

to  check  nothing  has  been  missed 

The Trust now has a co-mentoring audit completed by a senior nurse (Band 6 or above) who 
reviews  all  attendances 
regarding 
safeguarding/referrals. The Matron has oversight of this process and is emailed every morning 
with a summary of findings. Again, if themes are identified, the Matron, Nurse and clinician will 
be  emailed.  If  some  patients  have  left  without  being  seen,  an  incident  will  be  raised  and 
managed through the Trusts’ governance processes. Weekly documentation audits have been 
commenced since March 2025, with a focus on all aspects of nursing documentation. Themes 
are collated weekly and shared with the team on the safety huddle and individually for those 
staff members who require further support or training. Practice  Based Educators have also 
commenced  training  with  the  new  starters  around  documentation  and  the  importance  of 
accurate record keeping.  

There has been a redesign to the electronic triage form so that you cannot bypass the sepsis 
screening questions. The ED Matron has worked closely with system developers to create an 
e-Card Triage System with mandated sepsis screening which forms part of the sepsis bundle. 
The Manchester Triage System (MTS) is in place. All triage practitioners are registered on the 
MTS system and annual triage audits of all triage practitioners are in place (this is on-going). 
Triage training is a rolling programme throughout the year, ensuring any triage practitioners 
who  require  further  support  or  training  have  the  opportunity  to  access  the  programme 
supported and delivered by the triage train the trainers and practice-based educators.  

There has,  in  addition to  the  existing  Practice  Based  Educators,  been  a  recent  recruitment 
drive where the Trust have successfully recruited two further Practice Based Educators to help 
deliver training and learning across the organisation and they will commence in their roles in 
November/December 2025.  

Sepsis simulations (SIM)  are delivered monthly the latest being in  July 2025. Focus weeks 
have  been  held  in  April  2024  and  September  2024  for  both  adults  and  paediatric  ED,  in 
addition to a sepsis focus week in March 2025. Throughout the week commencing 14th July 
2025 there was an additional sepsis focus week aimed at all walk-in patients and there will be 
a further sepsis focus week commencing 15th September 2025 as it is World Sepsis Day on 
13th September 2025.  

The Trust now have in post a simulation co-ordinator who helps to arrange and facilitate all 
the organisations SIMs teaching across both adults and children’s emergency departments. 
Since 29th January 2025, the Trusts has facilitated 24 different simulation sessions and 17 of 
these have had sepsis as a primary or secondary learning outcome and there have been 181 
participants over this period of time. One in four simulations is now Children and Young Person 
specific.  

 
 
 
 
 
 
 
 
 The purpose of the SIM is to use members of staff in their own roles  (F2s, clinical fellows, 
middles grades, consultants and nurses) to allow the Lead Consultant to identify how confident 
staff members are in their roles and observing how they manage an unwell child in the realistic 
clinical space. It is also an opportunity to identify good areas of practice and learning resulting 
in the simulations being an invaluable teaching aid. Sepsis SIMs are performed on a monthly 
basis for both adult and paediatric ED but simulation training is carried out every Wednesday 
which  cover  various  topics  and  themes  including  but  not  limited  to;  Silver  Trauma  with 
urosepsis, cardiac arrest/Hyperkalaemia and Respiratory failure. A simulation training session 
was  conducted  on  30th  April  2025  specifically  for  meningitis  covering  A  to  E  assessment, 
treatment of meningitis and the causes and risk factors.  

The learning outcomes from the simulations can lead to actual changes in practice/procedure.  

Examples of this are: 

1.  We now have a white board in the Paediatric Resus Department which enables us to 

make important notes during a resuscitation 

2.  We  now  have  a  WETFLAG  chart  on  the  wall  in  Resus  -  this  enables  clinicians  to 

prepare emergency drug doses for resuscitation more quickly 

3.  All  North  West  Transport  Service  (NWTS)  guidelines  are  printed  and  kept  in  the 

Paediatric resus area for easy and quick access/reference 

4.  Specific training for Intraosseous (IO) insertion has been given to doctors in ED  

5.  We have regular resus trolley checks and a safety checklist 

On  4  December  2024,  the  CQC  commenced  a  responsive  assessment  of  the  services  for 
children and young people because of concerns around child death incidents. They carried 
out an unannounced inspection during 28 to 30 January 2025.   

During the inspection, the CQC spoke with 10 parents and young people who used the service 
and looked at 18 care records. They also spoke with staff, leaders and service partners and 
looked at policies and other documents relating to the service.  

The assessment report was published on 6 June 2025 and is publicly available on the CQC’s 
website.  The overall rating for services for children and young people stayed the same - the 
service  was  rated  as  good.   A  rating  of  good  was  awarded  in  all  domains  (safe,  effective, 
caring, responsive and well led).  The report covers some of the pieces of work the Trust has 
already highlighted above.  

In brief, the report states: 

•  The service had made improvements to processes for managing deteriorating health 
and sepsis management and had plans in place to make further improvement.   

•  The service had made significant improvements around staff training and processes 
for  managing  deteriorating  health  and  sepsis  management  following  child  deaths 
during 2023. Action plans were in place to further improve this. 

 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 •  The service had guidelines, pathways and screening tools that were based on national 
guidelines  for  the  management  of  children  and young  people  with  sepsis,  including 
neonatal  sepsis.  Staff  understood  how  to  identify  and  manage  sepsis  in  line  with 
policies and national guidelines. 

•  Training  in  aspects  of  sepsis  management  was  included  in  paediatric  life  support 
training  and  paediatric  acute  illness  management  courses  undertaken  by  staff. 
Additional in-house paediatric sepsis training had been developed and was planned 
for roll out during March 2025. 

•  Staff in the children and young people’s emergency department participated in regular 
sepsis  simulation  activities.  These  involved  multi-disciplinary  teams  managing 
scenarios to develop skills and identify learning. A number of doctors and advanced 
clinical practitioners had also been trained as sepsis fellows, who worked with clinical 
teams to champion learning and improvement. 

•  A  children  and  young  people’s  sepsis  audit  was  undertaken  during  August  to 
September 2024, following a previous audit in May 2024. The  audit was based on 7 
indicators  and  showed  improved  compliance  in  5  audit  indicators  since  May  2024. 
These  were  for  taking  blood  cultures,  administering  IV  fluids  within  1  hour,  use  of 
sepsis screening tools, implementing sepsis care bundles and completing full set of 
observations on admission. The audit showed further improvement was still required 
in 2 audit indicators; antibiotics prescribed within 1 hour of suspected sepsis and full 
set of observations undertaken at triage. 

•  The emergency department also undertook a separate monthly sepsis audit, based on 
10 random adult and children’s records. This showed an improving trend in compliance 
between April 2024 and December 2024. 

•  A sepsis action plan was in place to improve processes. This included actions planned 
or undertaken relating to continued audit and monitoring of compliance, further staff 
training and raised awareness through shared learning. 

I  consider  the  above  evidence  demonstrates  that  the  Trust  is  providing  training  for  sepsis, 
identifying learning and implementing these changes effectively and validates that the Trust is 
ensuring that sepsis is embedded in the minds of those who assess and treat children and 
young people.  

The Trusts’ work around sepsis continues and there is no intention for any of this to cease in 
the immediate future.  

Concern 2 - Trust is yet to fully implement the latest iteration of the National Institute of 
Health and Care Excellence’s Guideline Meningitis (bacterial) and meningococcal  
disease: recognition, diagnosis and management (NG240 Published 19 March 2024)  

The  National  Institute  of  Health  and Care  Excellence’s  Guideline  Meningitis  (bacterial)  and 
meningococcal disease: recognition, diagnosis and management has been implemented and 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 that Trusts’ meningitis guideline has been updated in line with NICE. The Trust has prepared 
and  shared  a  seven-minute  briefing  reaffirming  the  subtle  signs  of  meningitis  which  was 
distributed to all staff (consultants, trainees etc.) by email on 5th February 2025 and has also 
been shared at Clinical Paediatric Governance meeting on 13th February 2025.  

A meningitis audit was conducted in January 2024 to review those instances where we weren’t 
meeting the guidance. That audit did not highlight any missed cases.  

In February 2024, the Trust undertook a proactive investigation into child deaths.  The results 
of  this  investigation  were  shared  with  the  Care  Quality  Commission  (CQC),  and  the  Trust 
responded to associated information requests in May and July 2024. 

As mentioned above, on 4 December 2024, the CQC commenced a responsive assessment 
of  the  services  for  children  and  young  people  because  of  concerns  around  child  death 
incidents. They carried out an unannounced inspection during 28 to 30 January 2025.   

The report also identified the below additional learning around meningitis: 

•  The  service  completed  an  audit  in  November  2024  to  assess  staff  compliance  with 
NICE’s  recommendations  for  ‘meningitis  (bacterial)  and  meningococcal  disease: 
recognition,  diagnosis  and  management  (NG240)’.  The  audit  identified  good  staff 
compliance in standards  around  initial  assessment, taking  blood cultures  and blood 
sugars, undertaking correct investigations and computed tomography (CT) scans and 
antibiotic choice and duration. 

•  The  audit  also  identified  areas  for  improvement  in  some  standards  such  as  taking 
throat swabs, commencing IV antibiotics within 1 hour of meningitis being suspected 
and  post-discharge  follow-ups  for  bacterial  meningitis.  The  service  had  developed 
action plans and guidelines and policies for staff to aid learning and improvement. 

Concern  3  -  The  Locum  Consultant  in  Emergency  Medicine  who  completed  a  form 
indicating Lila was ‘Safe to Transfer’ to the Paediatric Emergency Department did so 
without  undertaking  any  examination  or  direct  assessment  of  her.  The  doctor  had 
previously filed a statement at court indicating he had undertaken a ‘preliminary visual 
assessment’ of Lila, but accepted in oral evidence that this was not, in fact, the case 

The Trust has changed its ‘Safe to Transfer’ process in ED. The Children and Young Person 
ED has moved into the same footprint as the main ED department as of July 2024. This means 
that if a child is screened positive for sepsis at triaged, the triage nurse would go to a senior 
clinician in ED and be commenced immediately on the sepsis bundle. That patient would be 
streamed to a cubicle for immediate review by a doctor. All the care is given in the emergency 
department and only if required to transfer to  paediatrics for admission would an SBAR be 
required.  If  too  unwell,  Paediatrics  would  come  to  ED.  The  form  that  the  doctor  signed  in 
December 2023 is no longer required. The transfer form used for Lila is no longer in use.  

The  Trust  has  spoken  to  the  doctor  concerned  who  has  reflected  on  his  practice  and  the 
implications of the statement of truth he signed. This  doctor is under the Trusts’ internal HR 

 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 review  process.  The  Trusts’  Responsible  Officer  has  been  engaging  with  the  relevant 
governing bodies throughout their review process which remains on-going.   

Since  the  inquest,  further  training  has  been  delivered  by  the  Trusts’  panel  firm  at  Grand 
Rounds on 25th June 2025 on statement writing including the implications of the statement of 
truth.  Grand  Rounds  is  an  open  attendance  to  all  medical  professionals  from  Health  Care 
Assistants to Consultants and is delivered every Wednesday and includes a variety of teaching 
topics and learning for staff.  

Legal Services are also hosting a Legal Conference on 2nd September 2025 and statement 
writing is an agenda item.  

Concern 4 - No medical record appears to exist of the examination of Lila which was 
undertaken by the Locum Registrar in Paediatrics which resulted in discharged from 
hospital.  The  absence  of  this  key  piece  of  evidence  serves  to  limit  the  ability  of  the 
Trust to derive all possible learning from Lila’s death 

The  locum  registrar  has  discussed  her  evidence  with  the  Trust  solicitor  for  Tameside  and 
Glossop Integrated Care NHS Foundation Trust as well as the doctor’s current responsible 
officer at her current organisation. She too has reflected on her own practice and understands 
the omission she made in relation to her documentation, something which she has insisted 
will not form part of her future practice.  

The importance of documentation is revisited at the Trust on a regular basis at the bi-monthly 
Medicine and Urgent Care Divisional Meeting as well as the Surgery, Women’s and Children’s 
Divisional Meeting. Legal Services also contribute to these meetings in relation to the learning 
from inquests and it is an area the Trust are continuing to monitor and develop. 

In  terms  of  investigations,  the  Trust  moved  to  the  Patient  Safety  Incident  Response 
Framework  (PSIRF)  in  May  2024.  This  sets  out  the  NHS’s  approach  to  developing  and 
maintaining effective systems and processes for responding to patient safety incidents for the 
purpose of learning and improving patient safety. This process replaced the previous Serious 
Incident Framework (2015). The comprehensive investigation for Lila came under the Serious 
Incident Framework. 

Under  the  Patient  Safety  Incident  Response  Framework  (PSIRF)  there  is  now  a  greater 
emphasis on engaging with those affected by the incident including patients, families and staff. 
Ensuring they are treated with compassion and be able to be part of the investigation. This 
was not  something that occurred  routinely  as  part  of the  Serious  Incident  Framework. This 
allows  families  and  patients  to  share  their  perspectives  and  will  formulate  part  of  the 
investigation/learning response. This new collaborative approach ensures that it is not solely 
a paper exercise or review of a patients’ medical records based on the view of the Trust but 
that it assists in providing focused terms of reference so that areas of concern can be reviewed 
and allows the organisation to evidence the learning that has and will take place following the 
patient safety incident.  

On behalf of the Trust, I want to express my sincere condolences to Lila’s family for their loss. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 I hope this response has provided assurance that the Trust has taken your comments and 
concerns seriously and action taken to minimise the risk of such an  event occurring again. 
Should you require any further information, please to not hesitate to contact me through the 
Legal Services Team on 0161 922 5020.  

Yours sincerely,  

Medical Director 
On behalf of 
Tameside and Glossop Integrated Care NHS Foundation Trust 

 (Chief Executive Officer)