Charlotte Alderson

“used by clinicians to assess infection in patients presenting to them, namely; CENTOR and FEVERPAIN. Either may be used by clinicians. Both systems use similar parameters to diagnose and indicate treatment. However, in their application to a given set of circumstances they can produce different outcomes, specifically in relation to the prescription of antibiotics. It is possible in Mrs ALDERSON's case that the use of the FEVERPAIN scoring system (as opposed to CENTOR) may have made a difference by indicating a prescription for antibiotics, which if taken on the day she was assessed by her GP, may have resulted in a different outcome. There is a need to review these scoring systems, drawing upon the most effective elements of each, with a view to providing guidance on a single scoring system that can”

“Evidence received during the Inquest indicated that a number of existing measures within the National Health Service are capable of modification to provide testing tools for the early identification of sepsis/risk of sepsis and which would better inform decisions to prescribe antibiotics. These include CRP, finger prick and lateral flow tests. The risks associated with sepsis and the speed with which a rapid deterioration can occur in patients without clear warning signs of sepsis being present, are well known. There is therefore a need for the expeditious development of measures which assist clinicians in the early identification and treatment of sepsis.”

“During the course of the evidence presented at this Inquest, the Court heard that the Interoperability toolkit (ITK) used to handover information between 111 and 999 services will on occasions fail, requiring the manual backup of a telephone call. This was identified as a national issue which, although not frequent, when it occurs carries a significant risk of critical information not being passed due to human error. I am concerned that in such circumstances the manual backup is not adequate and there is a risk that significant information is not passed thereby increasing a risk to life.”