Reports & recommendations

i. All Trusts must provide safeguarding training to all staff (appropriate to their role
and expertise) and Board members, including Non-Executive Directors. This training
should include how to deal with concerns and suspicions about deliberate harm caused
by staff.
ii. By March 2027, every existing contract of employment for work in an NHS hospital
must be amended to include an obligation on the employee to follow all relevant
safeguarding guidance, including the Suspicion of Deliberate Harm Protocol (at
Recommendation 9), for dealing with concerns and suspicions about deliberate harm.
Agency and bank staff contracts and all new contracts of employment must include the
same obligation.

NHS England must provide, by 31 March 2027, a clear and timed route to ensuring that
computer systems are harmonised across the NHS by December 2028. Work on the
development of a mandatory information standard with requirements for interoperability
between systems should be taken forward and implemented as soon as possible. This
should mean that data relating to babies and neonates in hospital may be entered on a
single occasion, be reviewed in a timely manner and facilitate continuous monitoring.1

i. All hospitals with a neonatal unit should name a ‘lead reporter’ with responsibility
for inputting data regularly (at least weekly) and reviewing real-time data viewers on
neonatal and maternity units in the MBRRACE system. Whilst the lead reporter does not
necessarily need to be a clinician, they must be trained to understand and interpret the
available data and able to explain and discuss it with clinicians.
ii. Save where data requires immediate action, in which case a report should be made to
the Medical Director and the Board immediately, the lead reporter should report to Trust
Boards at least every six months and advise:
a. whether any alerts or a need for investigation have arisen
b. the investigation or action plan in place.

Protocol
i. By 31 March 2027, NHS England must produce and distribute a one-page protocol
setting out the steps to be taken by managers when concerns or suspicions are raised
that a healthcare professional may have deliberately harmed a patient. The Suspicion
of Deliberate Harm Protocol must make explicit that:
a. It is irrelevant whether the person to whom the concerns have been expressed does
or does not believe they are true, as is the fact that the person raising the concern is
not sure.
b. Where concerns or suspicions of deliberate harm are being raised in good faith, they
must be acted upon immediately.
c. Only in cases where the concerns are obviously irrational or malicious (which
assessment must be recorded) will no further action be justified.
d. Pending investigation of a member of staff, action to protect patients by moving
the person suspected of causing harm is likely to be the first step.
e. The moving of a person suspected of causing harm and the investigation into
suspicions and concerns about a member of staff is a neutral act.
f. Safeguarding steps must be followed, as a result of which the police will become
involved.
Guidance
ii. Guidance of no more than two pages should accompany the protocol. It must set out
the factors to be considered when assessing the nature of the concerns and suspicions.
The reader should be directed to guard against their own biases, loyalties and prejudices.
The guidance should explain what should be said and when to those who are or who
may be involved with any investigation (such as patients, parents and staff). This must
include that patient safety comes first, and investigation is required. The guidance
should also explain that failure to follow the protocol will be a breach of contract by
an employee, as well as a breach of the relevant code of conduct.
Implementation
iii. Trusts must embed the Suspicion of Deliberate Harm Protocol and guidance within their
hospital.

i. The National Medical Examiner should, by 31 March 2027, prepare and distribute a
one-page document setting out all the steps to be taken by a medical examiner when
dealing with the death of a neonate.
ii. The revised SUDIC guidelines (see Recommendation 8 above) should be set out within
the good practice guidelines for medical examiners, not merely signposted.
iii. Medical examiners should ask direct questions of the attending practitioner as to
whether there is a concern that a child has been harmed or some other safeguarding
concern. Where there may be such a concern, the medical examiner should ensure
that there is a record made that day of the contact details of every doctor or nurse
who attended to the baby during life.
iv. There should be a pool of neonatologists who can assist medical examiners with
their work until such time as it is possible to appoint the appropriate number of
regional neonatologist medical examiners. Ring-fenced funding should be provided
for this purpose.
v. The medical examiner system should be reviewed again in 2027 by DHSC. The review
should include the adequacy of funding for medical examiners and their support staff
and offices. In particular, the question of whether the funding should be ring-fenced
must be addressed. Thereafter, reviews should be as directed by DHSC and NHS
England.

i. CQC should conduct without-notice inspections of hospital departments. Inspection
teams should include at least two current practising experts in the relevant field (in this
case paediatrics/neonatology).
ii. Inspectors should investigate what is happening in hospital departments and not accept
what they are told at face value. Where processes are being inspected, questions must
be asked to elicit the effectiveness of those processes.3
iii. Training should make explicit that CQC is responsible for ensuring the safety
of patients in hospitals and not just for checking there are processes in place which,
if implemented, should ensure patient safety. Inspectors and team leaders must always
approach an inspection of neonatal services not as a box-ticking exercise but as a way
to determine that babies in hospital are safe.

A new responsibility for auditing the implementation of the recommendations of statutory
inquiries into NHS bodies should be given to the National Audit Office. Funding for
appropriate additional staffing should be made available so that it may begin its work
by September 2027.