Dear Coroner Z Golombeck,

Re: Master Michael Chahwanda Regulation 28 – Action to Prevent Future Deaths

I have read carefully your report regarding the tragic and untimely death of Michael Chahwanda and have discussed this with senior colleagues within the RCPCH in order to respond to your request.

You have asked us to consider an amendment to the Red Book to include specific advice for Vitamin D supplementation in the postnatal period to be given by the attending Health Visitor.

Attached to this letter is the most recent PDF version of the Red Book, version
4.6 most recently updated in August 2020. Please refer to page 6 of this document on Vitamin D that recommends that all pregnant women, babies and young children from birth to 5 years should have a daily supplement containing vitamin D. It states that breastfed babies need vitamin drops from birth alongside breast milk. This is ratified in the College’s own guidance on vitamin D for children.1

NHS Choices states that all pregnant and breastfeeding women need 10 micrograms of vitamin D each day and should consider increasing this dose in the winter months.2

It is likely that the sad circumstances surrounding this child’s death is a professional practice issue, rather than an omission in College standards or guidelines. E-learning is available for child health professionals, including health visitors and midwives that signposts to the information hosted on the NHS Choices website for guidance around vitamin D supplements.3 These materials are endorsed and hosted by Health Education England.

1 https://www.rcpch.ac.uk/resources/vitamin-d-infants-children-young-people-guidance 2 https://www.nhs.uk/pregnancy/keeping-well/vitamins-supplements-and-nutrition/ 3 https://www.e-lfh.org.uk/heathy-pregnancy-pathway/antenatal/universal.html 5-11 Theobalds Road London WC1X 8SH -Phon

Thank you for raising this important case with us.

Dear Mr Golombeck,

I write in response to your Regulation 28 Report, dated 27 January 2021, regarding the tragic death of Michael Chahwanda. I would like to express my sincere condolences to his family.

We have considered the circumstances surrounding Michael’s death and the 2 key areas of concern raised in your report, which I will respond to in turn.

1. To: The Royal College of Paediatrics and Child Health and Department of Health and Social Care and The National Institute for Health and Care Excellence: To consider an amendment to the Red Book to include specific advice for Vitamin D supplementation in the postnatal period to be given by the attending Health Visitor. Such advice would be consistent with national guidance.

NICE’s guideline on vitamin D: increasing supplement use among at-risk groups (PH56) recommends that the developers of personal child health records (the 'red book') should add specific questions about the use of vitamin D supplements (see recommendation 8).

The red book (Personal Child Health Record (PCHR)) is currently overseen by a multi-disciplinary group hosted by the Royal College of Paediatrics and Child Health (RCPCH). Therefore, we consider the RCPCH will be best placed to consider amendments to the current content of the publication with regards to vitamin D supplementation.

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However, as the red book is becoming digitalised, NICE will liaise with NHSX and NHS Digital to obtain closer alignment between the digital content and NICE’s evidence-based guidance.

NICE also has a guideline on postnatal care up to 8 weeks after birth (CG37). This guideline includes advice on breastfeeding, and the management of common and serious health problems in women and their babies after the birth, and is currently in the process of being updated. The updated draft guideline includes the following new recommendation:

Inform women that vitamin D supplements are recommended for all breastfeeding women.

The draft guideline also cross-references to NICE’s guideline on vitamin D: increasing supplement use among at-risk groups (PH56).

We expect to publish the updated postnatal care guideline on 13 April 2021.

2. To: Department of Health and Social Care and The National Institute for Health and Care Excellence: To consider an amendment to the guidelines so that there is a directive for women (particularly those with an increased skin pigmentation and those who are breast-feeding) to take Vitamin D supplements. Also, to consider the provision of Vitamin D to women and babies who are at an increased risk of Vitamin D deficiency.

We consider that NICE’s current guideline on vitamin D (PH56) appropriately highlights the increased risk of vitamin D deficiency and the need to take vitamin D supplements in the population groups you refer to.

Recommendation 8 highlights the importance of ensuring health professionals recommend vitamin D supplement use among specific population groups (including infants and children aged under 4, breastfeeding women, and people with dark skin) whenever possible, and gives examples of when this could take place, such as during routine appointments and health checks, including antenatal and postnatal appointments.

The guideline glossary defines specific population groups as follows:

Although the entire population of the UK are at risk of having a low vitamin D status, evidence was only considered in regard to increasing the supplement use for these specific population groups:
• All pregnant and breastfeeding women, particularly teenagers and young women.
• Infants and children under 4 years (breast fed, non-breast fed and mixed fed).
• People over 65.
• People who have low or no exposure to the sun. For example, those who cover their skin for cultural reasons, who are housebound or confined indoors for long periods.

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• People who have dark skin, for example, people of African, African– Caribbean and South Asian origin.

All population groups are currently advised to take a supplement that meets 100% of the reference nutrient intake for their age group. The reference nutrient intake levels are noted above.

All infants and young children aged 6 months to 3 years are advised to take a daily supplement containing vitamin D in the form of vitamin drops. But infants who are fed infant formula will not need them until they have less than 500 ml of infant formula a day, because these products are fortified with vitamin D. Breastfed infants may need drops containing vitamin D from 1 month of age if their mother has not taken vitamin D supplements throughout pregnancy. ('Vitamin D – advice for supplements for at risk groups – letter from the UK Chief Medical Officers' Department of Health).

NICE recommends that the Department of Health should work with manufacturers to ensure vitamin D supplements are widely available for specific population groups including children aged under 4; pregnant and breastfeeding women; and people with dark skin, for example, people of African, African-Caribbean or South Asian family origin (see recommendation 1).

In addition, recommendation 6 focuses on how local authorities should improve accessibility, availability and uptake of Healthy Start supplements, such as by considering offering them free to all pregnant and breastfeeding women and children aged under 4 years.

While it is not mandatory to apply the recommendations made in PH56, they do represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service.

We do not consider that PH56 needs to be amended as a result of your correspondence. However, the issues raised by your report will be further considered when the guideline is next considered for review.

Dear Mr Golombeck,

Thank you for your letter of 27 January 2021 to Matt Hancock about the death of Michael Chahwanda. I am replying as the Minister with responsibility for child health and I am grateful for the additional time in which to do so.

Firstly, I would like to say how very sorry I was to read the circumstances of baby Michael’s death. I can appreciate how deeply distressing Michael’s death must be for his mother and family and it is important we do all we can to learn the lessons from Michael’s death to prevent future deaths.

I have noted carefully your concern about the provision of important information on vitamin D supplementation in the postnatal period.

I wish to assure you that we recognise the need to equip parents with appropriate health advice, particularly during the first months and years of their child’s life. We also recognise the need to support professionals working with parents to give individual, tailored support for the child and their parents or carers. That way, we can prevent problems from arising in the first place, rather than dealing with the consequences.

It is distressing that some infants suffer serious harm or even death as a result of vitamin D deficiency, and every case is a tragedy. We are determined to do everything we can to prevent these deaths.

Existing Government advice on vitamin D supplementation is based on recommendations from the Scientific Advisory Committee on Nutrition and is clear on the requirements for different population groups, such as breastfed infants.

I am aware that the Royal College of Paediatrics and Child Health (the RCPCH) has confirmed that advice on vitamin supplementation is provided in the Personal Child Health Record (also known as the ‘red book’1), which, as you know, is a national standard health

1 Personal Child Health Record (PCHR) | RCPCH

and development record given to parents and carers at a child’s birth. The information and advice contained in the red book is constantly under review, and the most recent version (version 4.6) was updated in August 2020. Advice contained in the red book stipulates that all pregnant women, babies and young children from birth to five years should have a daily supplement containing vitamin D, and it states that breastfed babies need vitamin drops from birth alongside breast milk.

I am informed that the National Institute for Health and Care Excellence (NICE) has advised you in its response that it will work with NHS Digital and NHSx as the red book is digitised to ensure content is aligned with the relevant NICE guidelines and recommendations on vitamin D supplementation. I am aware that NICE has also explained to you the advice contained within its current guideline on Vitamin D supplement use in specific population groups2.

Advice on vitamin supplementation is also provided through a variety of sources such as the NHS.UK website and the Start4Life social marketing campaign, which provides advice during pregnancy, birth and parenthood. This includes specific, directive, advice on vitamin D supplementation during pregnancy, breast-feeding and for babies and young children.

However, we appreciate that more can always be done, and we will review all NHS.UK and Start4Life references to vitamin D to ensure that the requirements for pregnant and breast-feeding women and their infants, particularly those with dark skin, are absolutely clear. I will discuss with my fellow Minister, Nadine Dorries, the importance of it being talked about between the midwife and mother.

In relation to the provision of vitamin D supplements to specific population groups at increased risk from vitamin D deficiency, the Scientific Advisory Committee on Nutrition is responsible for advising the Government on the vitamin D needs of the population.

In line with advice from the Scientific Advisory Group, the Department has put in place measures to provide vitamin D supplements to women and babies who are at increased risk. Through universal health and wellbeing reviews offered to new parents, health visitors provide targeted advice to parents on vitamin drops and where to get them. Pregnant women, new mothers and children under the age of four who are on low incomes and in receipt of defined social security benefits are entitled to free vitamin D supplements through the Healthy Start scheme. Healthy Start Vitamins for women and children contain a daily dose of 10 microgrammes of vitamin D. Under current advice from the Scientific Advisory Group, the Department does not plan to change current policy on the guidance and provision of vitamin D.

Finally, you may wish to note that we have just received a report from the Early Years Health Adviser, Andrea Leadsom MP, who has been leading a major review into improving health outcomes in babies and young children3. The review will consider the barriers that impact on early-years development, including social and emotional factors and early

2 Overview | Vitamin D: supplement use in specific population groups | Guidance | NICE

3 https://www.gov.uk/government/news/new-focus-on-babies-and-childrens-health-as-review-launches

childhood experiences, and seek to show how to reduce impacts on vulnerability and adverse childhood experiences in this stage of life.

I hope this response is helpful, and you feel reassured we are working on preventing baby deaths from Vitamin D deficiency. Thank you for bringing these concerns to my attention.

JO CHURCHILL