• Infant had been admitted to hospital but discharged after four hours
  • HSIB announced investigation after being notified of death
  • Will look at understanding the circumstances surrounding the infant’s acute illness

A national investigation into how well NHS staff recognise seriously ill and deteriorating infants has been launched, following the death of a three-month-old baby who had been sent home from hospital. 

The Healthcare Safety Investigation Branch announced the launch of a new national investigation today, after it was notified of the child’s death.

The safety investigation body said the youngster was admitted to hospital but discharged four hours later. Less than four hours after being sent home, the baby was brought back to hospital and died from a meningococcus-related disease. 

HSIB said its investigation will look at understanding the circumstances around how the infant’s acute illness was not recognised or acted on.

It said: “This will involve a review of staff training and preparedness for recognising and responding to the sick infant. The investigation will explore how clinical information is communicated, together with the transfer of information between people; including the voice of the parent/carer and handover of information between staff.”

It added: “The investigation will consider the system and environmental influences that impact on the decision-making process, taking into account the contextual factors that influence the effectiveness of existing track and trigger tools for acutely ill infants.”

HSIB was created in April 2017 as an independent investigation body for safety incidents. It aims to carry out no-blame investigations to uncover systemic causes of safety incidents and actions that could prevent them.

It is modelled similarly to the Air Accident Investigation Branch and uses human-factors approaches in its work.

The government has stated its intention to give HSIB full statutory independence, with powers to require organisations to cooperate and respond to its investigations.