Dear Mr Cox,

Re: The Late Izzah Fatima Ali – Regulation 28 PFD Report and Response

I write in response to the Regulation 28 Report to Prevent Future Deaths, dated 09 December 2025 and received on the 10 December 2025. This was issued following the inquest into the death of Izzah Ali which was heard over 17-18 November 2025 and concluded on 09 December 2025. I would like to take this opportunity to express my sincerest condolences to the family of Izzah Ali for their tragic loss. During the inquest, the evidence revealed matters giving rise to concern. Which are as follows:
1. There was a failure to recognise that ‘bottle fed’ is an incomplete description and requires an additional question of ‘what is in the bottle?’ – there was a lack of professional curiosity
2. During ante-natal and post-natal visits with a woman who did not speak English, no interpreter was involved, contrary to guidance. Please find below the response from the Trust and details of the actions taken in relation to the above concerns.

Chief Medical officer’s office Royal Cornwall Hospital Truro Cornwall TR1 3LJ

Response:
1. Izzah’s case has been widely shared across the organisation and has increased professional awareness, knowledge and confidence in asking the appropriate question on feeding in infants.

The Emergency Department are to change their language when asking parents about how babies are fed from ‘bottle’ to ‘formula’ – e.g. ‘is your baby formula or breast fed?’ In addition, ED documentation in terms of proformas for paediatric clerking in the ED by both medical and nursing staff will reflect this change. In relation to our paediatric team, completion of routine enquiry will be embedded into the admission proforma use for our inpatient children’s ward. “What is in the bottle?” has become a standard enquiry for us all in paediatrics and will be included in their admission documentation. Support can then be provided for families if indicated. Maternity services use routine enquiry about the exact nature of bottle feeding as a mandatory question at every safe opportunity making the identification of need or risk earlier.

2. I reiterate the contents of paragraphs 9 – 11 from statement dated 3 September 2025 (Interim Director of Midwifery at time of signing, now Director of Midwifery) which was produced into evidence at the hearing on 17 November 2025. Since Izzah’s tragic death, the Trust has already undertaken and has in place the following:
a. Enhanced Continuity Pathway developed and implemented
b. Pregnancy Circles implemented with face-to-face translators
c. Strengthened interpreter and language support in maternal care
d. Audits of interpreter and language support will be reported to the Clinical Audit Assurance software (AMaT) and through Perinatal Safety Trust Board report. This commenced in January 2025 and will continue to be audited every 3 months.

I hope that this letter provides both you and Izzah’s family with assurance that the Trust has taken seriously the concerns raised in your report and that the Trust has taken the appropriate action to prevent future deaths.

Dear Mr Fox RESPONSE TO REGUALTION REPORT TO PREVENT FUTURE DEATHS This formal response addresses your report submitted under paragraph 7, Schedule 5 of the Coroners and Justice Act 2009, and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, dated December 10, 2025. The report follows the tragic death of Izzah Fatima Ali, who passed away at 9 months old on September 7,
2024. Firstly, we wish to reiterate our deepest condolences to Izzah’s family. We acknowledge the significant implications of this case and the seriousness of the concerns expressed by the coroner. It is acknowledged that, during the inquest into the death of Izzah Fatima Ali, the evidence presented identified the following matter of concern:
• I wanted to ensure that the authors of the Essential Guide to feeding your Baby that I was told was being re-produced were aware of the facts of this case. I wanted them to reflect on whether the revised Guide needed to state that giving cow’s milk to an infant under the age of one was not advised because it ran the risk of preventing the absorption of iron from other sources and causing anaemia. I would like to assure you and the family of Izzah Fatima Ali that we have thoroughly reviewed the concerns raised in the Regulation 28 report and have either implemented or planned the actions detailed below. Funding secured for rapid mitigations
• Public Health has agreed to repurpose a £65,000 PHN underspend, enabling: £35k to rewrite/update the ‘Essential Guide to feeding and caring for your Mr Andrew Fox Senior Coroner for Cornwall & the Isles of Scilly H.M Coroner’s Office Pydar House Pydar Street Truro Cornwall TR1 2AY

reference

Date: 4th February 2026

Cornwall Council | Konsel Kernow New County Hall, Treyew Road, Truro, TR1 3AY T:

Cornwall Council Information Classification: CONTROLLED baby’ (including content on risk of animal milk/iron deficiency and translation to priority languages) and ~£30k to strengthen interpreter/translation solutions across the service. Essential Guide — update implemented
• The Essential Guide to feeding and caring for your baby (digital version) has been updated (December 15, 2025) to include explicit guidance on use of animal milk as a main drink and iron deficiency risk. This has been updated on the website and PDF version, and this can be translated to other languages using ‘Recite Me’ on the website. A new fully updated version will be written by the Specialist Health Visitor for infant feeding for Cornwall Council in collaboration with health colleagues, and this will be available in print as well as a digital version. Staff training and mandatory webinar
• A mandatory Infant Feeding webinar for all staff has now taken place, this included cultural baby feeding practices, professional curiosity and the use of professional interpreters. Staff that did not attend due to days off, annual leave, sickness etc. have been asked to watch the recorded webinar and sign to say that this has taken place. This will also include staff from other services who may be in contact with children who are bottle feeding, i.e., Core Parenting team, Family Hub staff etc.
• All staff across the service have been asked to complete their refresher training on cultural capabilities.
• We have also arranged for an all-staff webinar on cultural awareness.
• A Learning from Experience safeguarding webinar has also taken place from our safeguarding team within Public Health Nursing, this has included the process of attending coroner's court and also discussed the issues raised not only from our service but any learning that may have an impact on our service or that we can learn from.

Policy/Standard Operating Procedure alignment on interpreter/translator services across the organisation
• A meeting has taken place with the resettlement team within Cornwall Council on January 23, 2026. Within this meeting we discussed how we can make any improvements and work closely together to ensure we are meeting the needs of families where English is not their first language. Draft Standard Operating Procedure (SOP) on Interpretation and Translation has been updated to reinforce professional use of interpreters and safeguard practice which also includes the importance of documenting need in record. External best practice initiated
• Our South West, Department of Health and Social Care representative, from the Department of Health and Social Care. Health and Wellbeing Programme

Cornwall Council | Konsel Kernow New County Hall, Treyew Road, Truro, TR1 3AY

Cornwall Council Information Classification: CONTROLLED Manager for Maternity Children and Young People has reached out nationally to horizon scan national practice on translator services across Health Visiting and School Nursing and has shared examples of good practice, this can then be added to the updated SOP.
• We have met with the Senior Clinical Lead from the 0-19 Clinical Programme Unit from the Department of Health and Social Care to discuss terminology and advice regarding bottle feeding, and there has been no change nationally to the term bottle feeding. We will be providing further guidance and training to staff through the webinars arranged regarding professional curiosity in relation to formula/bottle feeding and we have updated all training that is provided in relation to infant feeding. The following time frame has been put in place: 0-4 weeks (risk reduction)
• The Essential Guide to feeding and caring for your baby (digital version) has been updated with translated versions available.
• Deliver mandatory webinar focusing on language/terminology, professional curiosity, and safe formula guidance by the end of January 2026.
• Confirm interpreter pathway and procurement/enablement options using the draft SOP as baseline. 1-3 months (embed)
• Finalise Interpretation SOP and publish, provide service wide training to all staff.
• Audit and Quality Assurance: add targeted checks on “what’s in the bottle” recording and interpreter usage.
• Communication to partners: harmonise terminology and advice; share Essential Guide update and SOP highlights. 3-6 months (assurance and demonstrate impact)
• Post‑implementation review: measure webinar completion, training compliance, interpreter bookings, and incidents.
• Parent‑facing assurance: update Family Hubs and Advice Line staff; align with national initiatives.
• A fully updated version of the Essential Guide will be produced within the next 4-6 months using underspend from Public Health Nursing.

Cornwall Council | Konsel Kernow New County Hall, Treyew Road, Truro, TR1 3AY

Cornwall Council Information Classification: CONTROLLED

I hope I have provided reassurance to you and the family of Izzah Fatima Ali about the learning that has and will continue to take place as a consequence of her sad death.

Dear Mr Cox.

Re: Izzah Ali deceased

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 10 December 2025, concerning the death of Izzah Fatima Ali who died on 7 September 2024 at the age of 9 months.

In advance of responding to the specific concerns raised in your Report for Cornwall Partnership NHS Foundation Trust (“The Trust”), we would like to express again our deep condolences to Izzah’s family for their loss.

Your concern for the Trust was that “There were multiple interactions with a wide variety of different healthcare professionals when it was noted Izzah was being breast and bottle fed. No inquiry was made to check that bottle fed meant formula fed or otherwise to establish what was in the bottles being given to Izzah. It was not identified that she was receiving cow’s milk until her last admission to hospital.

Page 2

On 6 August 2024, Izzah was seen in a Minor Injuries Unit and then referred to paediatric colleagues in Royal Cornwall Hospital. At that time, it is more likely than not that she had developed anaemia, and this was the cause of her pallor and distended abdomen”.

Following part 1 of the inquest, the Trust took the opportunity to explore the concerns raised in evidence which involve the minor injury unit’s involvement and learning in this very sad case.

It was suggested in evidence that the Trust may wish to consider whether clinicians may query what parents may be feeding their babies and whether this is breast milk, cow’s milk or formula. The Trust’s General Practitioner said in evidence, that he was content with the actions of escalation taken at the time of his consultation, however, in future, from an individual clinician’s perspective, he would query the content of the bottle, if a similar situation were to occur.

The Trust agrees that where nutrition may relate to the cause of an attendance at a Minor Injuries Unit, or any healthcare setting, it would be entirely appropriate to make further enquiries about the content of the bottle.

Actions taken:

Our Minor Injuries Unit staff have asked to ensure that, should there be any concern about a child’s nutrition and if it is considered this could be linked to an attendance, staff should ask for specific details, including what is being fed.

Staff have also been reminded that children attending our Minor Injuries Units should be weighed on each visit as a standard process, and this should be documented in the clinical records. For children aged 2 years and under, this should also be recorded by staff in the child’s red book, if it is available.

Page 3 Additionally, a reminder has been shared with all Minor Injuries Unit staff that if there are any concerns that nutrition may relate to the cause of an attendance, they should ask for the child’s red book to be presented at that or any future visit.

Thank you for bringing these important concerns to the Trust’s attention and please do not hesitate to contact us should you need any further information.