Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Alfie Lydon who died on 12 March 2024.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 15 July 2025 concerning the death of Alfie Lydon on 12 March 2024, sent to NHS England’s Chief Midwifery Officer. I am responding on behalf of the organisation in my capacity as National Medical Director but would like to assure you that the Chief Midwifery Officer has also been sighted on this response and reviewed your Report.

In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Alfie’s parents and wider family. NHS England is keen to assure the family and yourself that the concerns raised about Alfie’s care have been listened to and reflected upon.

Your Report raised the concern that the vast majority of hospital trusts do not have processes in place to document external calls from community midwives to hospital teams, and that this can result in a lack of continuity and escalation of care, particularly regarding parental concerns.

With regard to documenting communication between community midwives and staff working on acute sites, this would be a standard expectation in the provision of care for both those making and those receiving the calls. Both staff groups will typically utilise the relevant Trust’s Electronic Patient Record (EPR) system for either community midwifery services or hospital maternity / neonatal services, depending on which staff groups on the acute site are involved. This should allow them to record information directly within the patient’s record, which should be accessible to all system users regardless of setting. This is on the provision that the maternity service has the necessary digital infrastructure, including capabilities for offline working when in the community. Should this not be the case, Trusts should still ensure that they have effective processes and procedures in place for the recording of key information within the EPR and access for those caring for the patient.

Regardless of the EPR system in use, community midwives are expected to document any conversation that they have with other healthcare professionals in the patient notes, with the requirement for accurate documentation being a basic, core aspect of clinical care. This is made clear in both the Nursing and Midwifery Council Standards of proficiency for midwives and The Code, which describes professional standards of National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

4th September 2025

practice for nurses, midwives and nursing associates. It would also be expected that each organisation has a process to ensure that any community midwife notes are brought together with the hospital maternity / neonatal notes, if this is not an automatic feature of the digital system employed. In addition, the person receiving any call from a health care professional should have a means of documenting any advice given in the patient record.

Alfie’s case will be raised with the Neonatal Operational Delivery Networks and Regional maternity teams, with the expectation that they subsequently cascade to all maternity and neonatal units the importance of documenting such consultations.

The new Fit for the future 10 year health plan for England will also help address the issues raised in your Report through its commitment to the introduction of a new Single Patient Record (SPR), which will bring together all of a patient’s medical records into one place. It is intended that the SPR will be rolled out in maternity care first, ensuring that maternity teams have all of the information they need about previous consultations, medical history and stated preferences, helping them to provide high quality and personalised care.

NHS England’s National teams have also engaged with the East of England’s Regional Chief Midwife on the concerns raised in your Report. They advise that:

• Currently, 46% of maternity units in the region have digital care records and the expectation is that any discussions regarding clinical care are recorded in the EPR.
• The remainder of maternity units are expected to have digital records in place within the next 12 months.
• Some trusts within the region also use digital devices such as mobile phones to record clinical care conversations.
• The concerns raised in your Report have been shared with maternity and neonatal units across the region, with a reminder to staff to record discussions on electronic records where available. Where not currently available, staff have been asked to join up hand-held records with clinical records at the earliest available opportunity.

I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Alfie, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.

Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.

Dear Assistant Coroner R Brittain,

Re: RCPCH Response to the Inquest Touching the Death of Alfie James Lydon A Regulation 28 Report – Action to Prevent Future Deaths

Thank you for sharing your report with us regarding the tragic and untimely passing of Alfie James Lydon. I was very sorry to hear of Alfie’s death.

Colleagues at the college and I have considered your report carefully and note your concerns regarding a lack of processes in place to document external calls from midwives to hospital teams. We are pleased to note that the Trust involved has taken steps to rectify this. We note your continued concern this is undertaken on paper and is not simply a local issue.

We also note and support your observation and concern that a lack of contemporaneous, accurate and immediately available documentation of discussions between community and hospital teams could result in deaths in future similar circumstances. Our Facing the Future: Together for child health standards state that ‘healthcare professionals assessing or treating children with unscheduled care needs in any setting have access to the child’s shared electronic record’.

As a membership organisation we have no direct control over the mechanism(s) by which healthcare staff record their clinical communications. Our sphere of influence lies in nudging change at national level. Currently, there is a lack of legislation and guidance on exactly what information, when and how it should be shared between agencies. In practice, our members (paediatricians) have reported difficulties in exchanging information, which may be a result of poor communication between professionals and/or a lack of interoperable information systems available to effectively share information. Use of the NHS number as a single unique identifier for children will overcome these barriers and enable information to be shared more easily between agencies and services. This is something RCPCH have long campaigned for and will continue to do so as we see implementation of the new NHS 10 Year Plan.

We agree with your observation and concern that a lack of record keeping can lead to a lack of continuity and escalation of care, particularly with regards to parental concerns. RCPCH are actively supporting the role out of Martha’s Rule, an inpatient safety initiative currently being piloted in England which aims to empower all staff, patients and their families to seek an independent medical review if they feel their concerns about a patient’s care are not being adequately addressed. The rule is designed to give families the ability to directly

request an expert review by a senior clinician not within the immediate care team, potentially identifying critical issues before they result in harm. 

By establishing this right to an independent review, Martha’s Rule improves ability to recognise and respond to deterioration by incorporating parents and families as part of the team. It formalises an escalation route for parents, carers and families to use to ensure their concerns are listened to and acted on and encourages transparency and collaboration. RCPCH contributed to the early working groups for Martha’s Rule and we continue to engage with NHS England as data from the pilot sites emerge. Martha’s Rule does not extend into the community at present, but learnings from Martha’s Rule could in future be applied in the community setting.

Thank you for seeking our views and reminding us of the importance of this work. Our sincere condolences are with Alfie’s family.