Leicester Royal Infirmary confirms multiple failings led to death of Jack Adcock

Leicester University Hospitals NHS Trust has released a sudden untoward incident report to the online publication, Pulse which was prepared into the circumstances surrounding the death of Jack Adcock on 24.8.11. This confirms that no single failing caused his death but that there were 6 significant failures including failing to communicate abnormal blood results; failure to observe, record and monitor; ambiguous policies to escalate observation; poor handover procedures and failing to engage a senior cardiologist in a timely manner.

The report goes to the heart of a the system of healthcare in place at he Children’s Hospital and will raise concerns over generalised poor practice. It is also likely to add further fuel to the demands to review the decisions to strike off Dr Bawa-Garba and Nurse Isabel Amaro as a consequence of Jack’s death amid suggestions that they have been held directly responsible for a system of healthcare that broke down on many levels.