James Philliskirk

“Junior staff not knowing when to escalate concerns”

“Unclear guidance in the handbook relating to chicken pox and reinfection and the need for aggressive antibiotic treatment if reinfection occurs soon after the initial infection”

“Confirmation bias affecting clinical reviews”

“Lack of proper assessment of existing skin lesions in chicken pox even where identified by parents”

“Lack of knowledge of the risk of secondary complications from recent chicken pox infection in the emergency department”

“Insufficient weight on GP referral when not through the identified route of referral (ie presentation straight to A&E which amounts to 25% of referrals). I heard evidence that an IT system is in development to resolve this however engagement of NHS Digital and the Commissioners is required to progress. For the avoidance of doubt, had the GP referral been processed in the usual way [the deceased] would have gone through to the medical unit and the result would have been senior oversight and a strong likel”