Jury Concludes 28 Year Old Man Dies by Natural Causes Contributed to by Neglect at Aintree A&E
19TH SEPTEMBER 2018
The family of the late Tom Cribley, hear after a 7 day inquest,
that Tom’s death was caused by natural causes which was
contributed to by neglect and failures in procedure at
Aintree A&E Department.
Prosperity Law, Liverpool, which acts for the family of the
late Tom Cribley, advises that the 28 year old attended
Aintree A&E on the 18th February 2017 with a rash,
headaches, neck stiffness and vomiting, stomach cramps,
joint and muscle pain all over his body. He presented in a
wheelchair as he was unsteady on his feet, disorientated and immobile. He was
provisionally diagnosed with gastroenteritis and was treated with fluids, anti-sickness
medication and paracetamol. He subsequently died from meningococcal septicaemia on 20th
February 2018 after catastrophic failings in both procedure and urgency to provide antibiotic
The Jury confirmed what the family has suspected for so long and confirms their belief that
had Tom received the appropriate antibiotic treatment within the Emergency Department, he
would still be alive today. Instead almost 5 ½ hours of delay prevailed before appropriate
treatment was prescribed.
One of the most concerning aspects for the family arising from the Inquest was the fact that
the Care Quality Commission Report dated 27th September 2016 outlined areas for
improvement and outlined the steps the Trust MUST take to improve.
These were all measures that should have been adopted in the 5 months prior to Tom’s death
however Tom’s treatment and subsequent death highlighted the Trust’s failure to ensure that
all staff adhered to the mandatory steps outlined by the CQC.
Eimear Lunny from Prosperity Law LLP who represents the family, says that the family want
to help raise awareness of Sepsis and the early symptoms and ensure that all medical and
nursing staff are fully trained to identify the signs and commence antibiotic treatment as soon
as possible. Tom’s father, Alex Cribley says that they do not want the same failures to result
in another needless loss of life and want to ensure that another family do not have to go
through the devastation and agony that they suffer and continue to deal with on a daily basis.
The Jury concluded that Tom Cribley’s death was caused by natural causes which was
contributed to by neglect due to the following points:-
- There was a failure to record and document the rash at triage stage
- There was a failure to consider concerns of the family throughout
- There was a failure to complete pit-stop process, resulting in delay of bloods being taken
- There was a failure to monitor and record observations correctly throughout
- There was a failure to document MEWS score and monitor MEWS
- There was a failure to recognise and escalate deteriorating MEWS score
- There was a failure to apply clinical judgement by observing Tom’s physical presentation factoring in younger patients compensate better
- There was a failure to consider differential diagnoses
- There was a failure to assess and re-assess consistently throughout
- There was a delay in confirmation of blood results being provided to medical staff caring for Tom
- There was a consistent failure of communication between all staff
- There were reported insufficient staffing levels
- There was a failure to escalate the urgency of Tom’s condition to Critical Care
- Action plans as a result of CQC report April 2016 were not implemented successfully shown by Tom’s death being an exact reflection of these failing reported 10 months prior to his death.
- The Jury found that antibiotic intervention should have been started at 18.50 as evidence shows 3 nurses showed (verbally) concerns of possible meningitis rash. A Senior House Officer also considered condition as took action to research meningitis rash on computer.
- The evidence heard reports that as long as no allergy to antibiotics, they are able to be administered as a pre-caution as part of differential diagnosis.
The Care Quality Commission Report dated 27th September 2016 outlined areas for
improvement and outlined the steps the Trust MUST take to improve, which included the
- They must ensure that staff undertake and record patient observations consistently and accurately
- They must ensure that staff adhere to the modified early waring score (MEWs) and sepsis policies that the trust has in place to minimise risk of harm to patients
- They must ensure that the that staff perform repeat observations in line with the clinically indicated MEWS trigger
- They must ensure that staff trained and competent to identify and escalate the deteriorating patient
- They must ensure staff compliance with mandatory training is improved in a timely way
- They must ensure that staffing levels in all areas adhere to the safer staffing requirements
- They must ensure that patient records are completed contemporaneously and reflect the care provided to patients.
The family are represented by Prosperity Law LLP and all queries should be made to
For further information, please contact Eimear Lunny at Prosperity Law LLP on 0151
958 0057 or
Prosperity Law LLP is based at No 4 St Paul’s Square, Liverpool, L3 9SJ