Jack Adcock is not the first patient to suffer from a mix up in his notes but a failure to treat his symptoms has lead to a successful criminal prosecution. This highlights the on-going issue of NHS staff failing to treat the symptoms shown by patients. On this occasion there was a case of mistaken identity and no action was taken to treat Jack who was showing sign of sepsis following his pneumonia.

Often mix-ups occur and can lead to a patient suffering. This can be a delay in dealing with pain but in Jack's case, the most serious consequences unfolded.

In a case such as this, there will be an internal investigation, it is through that the hospital will learn where the failings occurred. How does the NHS stop this from happening again? Surely the issue of staff to patient ratios will be relevant. With the winter months approaching, we know the NHS uses more agency ant staff. The systems need to be in place to make sure those staff have the correct notes for the correct patients and the time to read and understand them if Jack's tragedy is not to be repeated.