Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0096, written 13 Feb 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 13 Feb 2026 |
|---|---|
| Reference | 2026-0096 |
| Deceased | Edward Jones |
| Coroner | Oliver Longstaff |
| Coroner area | West Yorkshire (East) |
| Category | Child Death (from 2015) · Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
OFFICE OF THE SENIOR CORONER for the County of West Yorkshire (Eastern District) His Majesty’s Coroner’s Office The Coroner’s Courts Burgage Square Wakefield WF1 2TS Telephone: 01924 302180 Email: hmcoroner@wakefield.gov.uk REGULATION 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Chief Executive, NHS England 1 2 3 4 CORONER I am Oliver Robert Longstaff, HM Area Coroner for the Coroner Area of West Yorkshire (East). CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of The Coroners (Investigations) Regulations 2013. INVESTIGATION and INQUEST On 28/02/2023 I commenced an investigation into the death of Edward Richard Jones who died in the Leeds General Infirmary (“LGI”) on 18th February 2023, 18 days after his 5th birthday. The investigation concluded at the end of the Inquest (which was held with a jury) on 17/12/2025. The medical cause of death was 1a) Bacterial Sepsis; 1b) Invasive Group A Streptococcus. In summary, the jury’s narrative conclusion to the inquest reflected that Edward died from the effects of a septic response to Invasive Group A Streptococcus Disease, his death being contributed to by: i) a failure to respond adequately to a continuously high PAWS score that reached 20; ii) a failure to repeat a venous blood gas that had shown a raised lactate and would, if repeated, have shown a worsening lactate; and iii) a delay in giving Edward antibiotics until he had been in the Paediatric Emergency Department (“PED”) for between 10 and 11 hours. CIRCUMSTANCES OF THE DEATH Edward died from streptococcal sepsis, but this was confirmed only after his death when blood cultures taken before death grew Group A Streptococcus bacteria. Edward had been promptly assessed upon presentation to the LGI PED with abdominal and leg pain, diarrhoea, previous vomiting and dehydration. His diagnosis was unclear, but a differential included malignancy, hepatitis and intra-abdominal surgical pathology. A venous blood gas that had shown a raised lactate was not repeated, and a subsequent failure in communication gave the erroneous impression to the Paediatric Registrar that the venous blood gas had in fact been repeated and was now normal. The hospital trust’s Sepsis Screening Tool was not used at any time. Shortages in both medical staff and beds on the general paediatric ward compromised Edward’s cllinical management, in that shared care between the Paediatric Emergency Medicine and Paediatric General Medicine teams was prolonged while EJ remained for an extended period (up to 13 hours in all) in the PED. The indication for antibiotics was considered several times, but on each occasion prior to Edward’s severe clinical deterioration the threshold was not thought to be reached. The hospital trust formally admitted that a decision to administer antibiotics should have been made at each of these occasions. The presence of upper thigh pain and elevated CRP were not given sufficient weight and a lack of pyrexia was falsely reassuring. Despite potential alternative diagnoses, antibiotics should have been administered as direct harm would have been unlikely and it would have been possible to stop them once sepsis had been excluded on blood culture or an alternative diagnosis reached. Antibiotics for suspected cholangitis were eventually prescribed following an ultrasound scan that was suggestive of some gall bladder or liver pathology, but there was a delay of between 60 and 90 minutes in these being administered. CORONER’S CONCERNS During the course of the Inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – The inquest was told it is acknowledged nationally that there is no Sepsis Screening Tool which is validated for use in Paediatric Emergency Departments or has a sensitivity or specificity which makes it a useful tool for escalation within a Paediatric Emergency Department. LTHT has developed a Sepsis Screening Tool (SST) which is designed to be used by relatively junior nursing staff to improve the likelihood of considering sepsis and therefore requesting a senior medical review. The SST is intended to be completed at admission or if there is a clinical deterioration, such as an increase in PAWS score to 10 or above. The tool contains various checkbox items that if present suggest a high risk of sepsis. These include abnormal respiratory rate, mottling, rash or appearing blue, high heart rate, low blood pressure, altered conscious level and parental or health professional concern. High temperature needs to be 38 degrees C or more and then only in patients less than 4 months old so is less discriminatory. 5 There are secondary checkbox items indicating a moderate risk of sepsis including new leg pain, cold extremities, reduced urine output and temperature at any age greater than 39 degrees C. A single positive score mandates urgent assessment by a senior decision maker defined as a doctor of ST4 grade or higher, or equivalent allied health professional and if sepsis is confirmed to ensure prompt management, including giving IV antibiotics within 60 minutes. The SST tool is not designed to diagnose sepsis directly as this is the task of the senior decision maker but rather to prompt a targeted assessment, which will confirm sepsis or specifically eliminate it. Acknowledging that the trust’s SST had not been deployed in any assessment of Edward that was undertaken in the LGI PED, a trust witness told the inquest that work was ongoing to ensure a consistent application of the SST as between the PED and the paediatric in-patient units at the Leeds Children’s Hospital. As a coroner making a report of this nature, it is not for me to recommend to any third party that the Sepsis Screening Tool developed by the Leeds Teaching Hospitals Trust, or any document like it, should be either more widely disseminated to, or adopted as official guidance for, Paediatric Emergency Departments across England and Wales. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you or your organisation have the power to take such action. I have been advised by Professor , Chief Executive, National Institute for Health and Care Excellence (to which 6 organisation this report was originally sent), that your organisation is more appropriately placed to act upon it. I attach a copy of Professor letter to me dated 05/02/2026, together with its enclosures. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 10/04/2026. I, the Coroner, may extend the period. 7 Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons or their legal representatives: Edward’s parents; Leeds Teaching Hospitals Trust. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. She may send a copy of this report to any person who she believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. Signed: OLIVER LONGSTAFF Area Coroner West Yorkshire (E) Date: 13 February 2026 8 9
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Oliver Robert Longstaff
HM Area Coroner for West Yorkshire (East)
Coroner’s Service
71 Northgate
Wakefield
West Yorkshire
WF1 3BS
By Email:
Dear Coroner,
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
2nd April 2026
Re: Regulation 28 Report to Prevent Future Deaths – Edward Richard Jones
who died on 18th February 2023.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 13th
February 2026 concerning the death of Edward Richard Jones on 18th February 2023.
In advance of responding to the specific concerns raised in your Report, I would like
to express my deep condolences to Edward’s parents and family. NHS England is
keen to assure the family and yourself that the concerns raised about Edward’s care
have been listened to and reflected upon.
Your Report raises concerns that nationally there is no sepsis screening tool which is
validated for use in Paediatric Emergency Departments. You highlighted that Leeds
Teaching Hospital Trust have developed a local sepsis screening tool.
NHS England rolled out the National Paediatric Early Warning System (NPEWS) in
November 2023. The NPEWS is a national standardised approach of tracking the
deterioration of children in hospital. The aim of the NPEWS is to allow for consistency
in how deterioration in children is recognised. The NPEWS incorporates a sepsis
trigger which encompasses the Academy of Medical Royal Colleges guidance. A
sepsis trigger is a set of criteria, in this case the NPEWS ‘score’, which is used to
trigger a review of a patient.
The NPEWS has been adopted by NHS England, the Royal College of Paediatrics
and Child Health (RCPCH) and the Royal College of Nursing (RCN). Since it's launch
it is the preferred model of care, with over 70% of Trusts using it or developing plans
to use it.
The RCPH and NHS England are currently trialling an Emergency Department (ED)
NPEWS, and this should be published this year. Both RCPCH and Royal College of
Emergency Medicine (RCEM) fully support the introduction of ED NPEWS.
As part of the 10 Year Plan, the Government announced that it would create a first
wave of ‘Modern Service Frameworks’ in 2026, to identify interventions, standards and
innovations that will support consistent, high quality, and high value care. The first
wave includes a Sepsis Modern Service Framework and publication is anticipated in
Summer 2026.
The Sepsis Modern Service Framework will focus on the prevention, identification,
escalation and treatment of sepsis and severe infection across all age groups. Many
of the challenges in this case are recognised in the Modern Service Framework. It will
recommend specific actions such as the need for better tests to identify the presence
and type of infection, antimicrobial treatment options, better tools to predict the
likelihood of clinical deterioration, and improvement in compliance with evidence-
based processes of care, including the timely prescription and administration of
antimicrobials. The Modern Service Framework will support the development and
implementation of better technologies and treatments, and improved implementation
of best practice.
Regional Response
The NHS England North East and Yorkshire Regional Team have liaised with the West
Yorkshire Integrated Care Board (ICB) regarding your Report. They advised us that at
the inquest, the Trust accepted that they had failed to recognise sepsis in a timely
manner, and that this contributed to a delay in the administration of antibiotics which
could have prevented Edward’s death.
The Trust conducted an investigation which noted, that their 'Paediatric Sepsis
Screening Tool' was not used. Several factors contributed to this, but a central concern
was that the role of the tool and its interactions with the Paediatric Advanced Warning
Score (PAWS) escalation process in the Emergency Department was not clear.
At the time of the inquest, the Trust was able to assure you that their sepsis screening
tool was embedded and in regular use in the ED. However, the Trust views this work
as an ongoing process, and the use of the tool is regularly audited and sits alongside
a rolling education programme. Audit is conducted on a monthly basis and overall
compliance with the tool (which covers, screening, re-screening, observation
completion, and medical review) is currently between 70-80%. This data is shared with
and monitored by the senior ED team.
I would also like to provide further assurances on the national NHS England work
taking place around the Reports to Prevent Future Deaths. All reports received are
discussed by the Regulation 28 Working Group, comprising Regional Medical
Directors, and other clinical and quality colleagues from across the regions. This
ensures that key learnings and insights around events, such as the sad death of
Edward, are shared across the NHS at both a national and regional level and helps us
to pay close attention to any emerging trends that may require further review and
action.
Thank you for bringing these important patient safety issues to my attention and please
do not hesitate to contact me should you need any further information.
Yours sincerely,
National Medical Director
NHS England
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