Table 2

Avoidable primary care factors.

Age	Primary care factor	Fatal consequence
1 month	Delay in hospital admission in neonate with respiratory distress	Pneumonia

2 months	Failure to recognise severity of respiratory infection	Pneumonia secondary to pertussis

4 months	Breathlessness attributed to bronchiolitis in child with congenital heart disease	Heart failure

7 months	Failure to administer pneumococcal vaccine on request	Pneumococcal meningitis

8 months	Failure to recognise severity of secondary infection in chickenpox	Septicaemia

9 months	Failure to administer pneumococcal vaccine on request	Pneumococcal septicaemia

1 year	Inadequate safety netting	Pneumococcal meningitis

1 year	Failure to recognise severe dehydration	E. coli diarrhoea

3 years	Cough and fever diagnosed as ‘throat infection’	Empyema and septicaemia

6 years	Vomiting and pallor diagnosed as ‘viral infection’	Viral pericarditis

8 years	Failure to attend follow-up GP appointment following asthma exacerbation	Severe acute asthma

8 years	Myalgia and fever diagnosed as ‘flu’	Pneumococcal meningitis

8 years	Repeated failure to recognise severity of infection over 7 days	Viral pneumonia

12 years	Failure to recognise importance of respiratory symptoms	Staphylococcal pneumonia

14 years	Exceptionally reported from quality indicators for failure to attend	Acute asthma

15 years	Failure to follow up poor asthma control	Acute asthma

16 years	Prescribed epilepsy medication had run out	Drowned in bath during seizure

16 years	Severe acute infection diagnosed and treated as asthma	Pneumonia