Dear Mr Ian Pears Re: Regulation 28 Report to Prevent Future Deaths – Maya Zab, 6th August 2020 Thank you for your Regulation 28 Report dated 16 September 2021 the death of Maya Zab on 6 August 2020. Firstly, I would like to express my deep condolences to Maya’s family. I note that the inquest last year concluded that Maya’s death was a result of: 1a Multiorgan Failure 1b Chronic Severe Microcytic Hypochromic Anaemia with Severe Iron Deficiency Further following the conclusion of the inquest, I note that you have raised the following concerns within your Regulation 28 Report for NHS England to consider: During the course of the evidence it became clear that in the Yorkshire & Humber region there has been an increased incidence of severe nutritional anaemia in 2020 in a paediatric setting, resulting in 2 deaths, Maya’s death being one of the two. The witness had not seen any deaths previously in her career. The witness had consulted 9 colleagues over the data. They surmise that a number of factors arising indirectly from the pandemic may explain the findings:
1. The “stay at home” message resulted in less 1 to 1 consultations, so health professionals were not able to spot the signs of anaemia.
2. Limitation of social contact meant other professionals and friends and family were not able to report concerns about a child’s health. National Medical Director & Interim Chief Executive, NHSI Skipton House 80 London Road London SE1 6LH 26th November 2021

3. Widening of socio-economic inequalities (including unemployment and reduced household earning capacities) means that certain members of society are not able to purchase a balanced, good quality nutrition for their children.

Whilst contact with the NHS was reduced during the pandemic, there was also a clear narrative that the NHS remains open for patients who need care, and this remains the message. NHSEI is working hard to restore services across the country.

We recognise the impact the pandemic has had on the delivery of health visiting services. With the onset of COVID-19, some public health nurses were redeployed, however I can confirm that they were all repatriated by the end of July 2020.

In response to Winter Planning in 2020, Public Health England and NHSEI Chief Nurses, together with the Local Government Association, wrote to Directors of Nursing across the country to advise that professionals supporting children and families, such as health visitors, school nurses, designated safeguarding officers and nurses supporting children with special educational needs, should not be redeployed to other services and should be supported to provide services through pregnancy, early years and to the most vulnerable families. (Joint letter on Winter Planning: Support to Children and Families, 7 October 2020 | Local Government Association.)

Further an updated health visiting and school nurse service delivery model, together with commissioning guidance, was also published in March 2021. (Health visiting and school nursing service delivery model - GOV.UK (www.gov.uk).)

Even before the start of the pandemic, I can confirm that local authorities had a mixed model of delivery for health visitors. Specialist community public health nurses should use their clinical judgement to identify whether virtual, other digital or blended approaches can be used to support the needs of a child or family. During the pandemic, community health services have continued to provide such support, albeit with greater use of digital and remote technologies and the prioritisation of higher needs families.

I am able to confirm that DHSC are currently working with academics from Keele University to identify available evidence on the impact of digital technologies on public health service delivery to children, young people and families. The specific objective of this work is to identify the quality of digitally delivered services in relation to quality of engagement and development of therapeutic relationships. This evidence will then be made available to local service commissioners, their providers and professionals to inform future service design.

In terms of your concern regarding the widening of socio-economic inequalities, I can confirm that NHSEI are working to integrate care across the country with a particular focus on addressing inequalities and supporting children, young people and their families who may be vulnerable.

It was agreed that working with the NHS Business Services Authority (NHS BSA) to raise the profile and uptake of the Healthy Start programme would benefit both

pregnant mothers and children to provide children with the best start in life regardless of circumstances.

The Healthy start programme helps parents with children under the age of 4 and pregnant women to buy healthy food and milk. The scheme is in the process of transferring from paper vouchers to a digital cards, this will support quicker application decisions, allow use of the cards anywhere that accepts Mastercard®, automatic top up every 4 weeks, allows partial use of allowance (not previously available) and is discreet payment option.

National data sets do not show any national or regional increases in malnutrition. The data used was the secondary user service (SUS) data in the NHS England national clinical data repository (NCDR), the equivalent data is available on the NHS Digital website, where the data is available as a provisional dataset. The SUS malnutrition data using ICD diagnosis codes D508 - Other iron deficiency anaemias and D509 - Iron deficiency anaemia, unspecified, in any position (primary or secondary) does not show any significant increase nationally or regionally. The numbers regionally by month are generally quite low and can vary considerably month to month however the overall trend shows no significant increase. 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 Mr Pears, Thank you for your letter of 16 September 2021 to the Department of Health and Social Care about the death of Maya Zab. I am replying as Minister with portfolio responsibility for Child Health and I am grateful for the additional time in which to do so. I would first like to say how deeply saddened I was to read the circumstances of baby Maya’s death. To lose a child, and at such a young age, must be devastating and I offer my heartfelt condolences to her parents and all who loved and knew Maya. In preparing this response, my officials brought your concerns to the attention of the Regional Director of Public Health in the North East and Yorkshire, and made enquiries with NHS England and NHS Improvement (NHSEI), to which you also issued your report. NHSEI advises that data relating to diagnoses of iron deficiency anaemia1 does not show any significant increase nationally or regionally. The numbers regionally, by month, are generally quite low and can vary considerably month by month. However, the overall trend shows no significant increase. I hope this information is helpful. Of course, it is distressing that some infants suffer serious harm or even death as a result of poor nutrition, and I wish to assure you that we are determined to do all we can to prevent these deaths. 1 Secondary User Service (SUS) data, NHS England national clinical data repository. ICD diagnosis codes D508 ‘Other iron deficiency anaemias’, and D509 ‘Iron deficiency anaemia, unspecified, primary and secondary care.

We recognise the need to offer universal support to families with infants. The Healthy Child Programme: 0-5 years2 aims to offer every family five health and wellbeing reviews (from prenatal to infant) that are universal in reach and personalised in response. These should be face-to-face, delivered by a health visitor, or by another qualified professional under their supervision. There may also be more intensive home visiting support for vulnerable families. Where necessary, health visitors offer additional support to families and refer them onto other services.

In the course of their reviews, health visitors use clinical judgement alongside formal screening and assessment tools to identify health and development needs, safeguarding concerns and provide personalised advice and guidance to families.

Universal services remain essential for keeping children safe and for primary prevention, identifying needs and areas for support before a situation becomes an issue that needs to be addressed. Health visiting services are targeting resources to those where support is most needed. The spend per head in the most deprived areas is higher compared to the least deprived areas where spend per head is lower.

We recognise the impact the pandemic has had on the delivery of health visiting services. With the onset of COVID-19, some public health nurses were redeployed, but were repatriated by the end of July 2020.

In response to winter planning in 2020, Public Health England and NHSEI Chief Nurses, together with the Local Government Association, wrote to Directors of Nursing to advise that professionals supporting children and families, such as health visitors, school nurses, designated safeguarding officers and nurses supporting children with special educational needs should not be redeployed to other services and should be supported to provide services through pregnancy, early years and to the most vulnerable families3.

An updated health visiting and school nurse service delivery model, together with commissioning guidance, was published in March 20214.

Even before the start of the pandemic, local authorities had a mixed model of delivery for health visitors. Specialist community public health nurses should use their clinical judgement to identify whether virtual, other digital or blended approaches can be used to support the needs of a child or family. During the pandemic, community health services have continued to provide support, with greater use of digital and remote technologies and prioritisation of higher needs families.

We are working with academics from Keele University to identify currently available evidence on the impact of digital technologies on public health service delivery to children, young people and families. The specific objective of this work is to identify the quality of digitally delivered services in relation to quality of engagement and development of

2 Policy paper overview: Healthy Child Programme: Pregnancy and the First 5 Years of Life - GOV.UK (www.gov.uk)

3 https://www.local.gov.uk/joint-letter-winter-planning-support-children-and-families-7-october-2020 4 https://www.gov.uk/government/publications/commissioning-of-public-health-services-for-children/health- visiting-and-school-nursing-service-delivery-model

therapeutic relationships. This evidence will be made available to local service commissioners, their providers and professionals to inform future service design.

The Government does not have any plans to introduce policies to specifically target nutritional anaemia in children. However, the Government’s efforts to promote a healthy balanced diet for children contribute to this goal by encouraging the intake of food rich in nutrients essential to preventing anaemia, such as iron.

Government advice on a healthy, balanced diet is encapsulated in the UK’s national food model, the Eatwell Guide5. The Eatwell Guide is a visual representation of the types and proportions of foods needed for a healthy balanced diet. The Eatwell Guide includes a variety of iron rich foods, such as, fortified cereals, red meat, vegetables, nuts, eggs and fish.

In addition, the Healthy Start Scheme supports hundreds of thousands of pregnant women and families on lower incomes to make healthier food choices. Pregnant women and families with children aged under four and over receive one voucher per week, worth £4.25, and families with children under one receive two vouchers, worth £8.50 in total, every week. These vouchers can be used to buy, or be put towards the cost of, fresh, frozen or tinned fruit and vegetables, fresh, dried and tinned pulses, plain cow’s milk and infant formula.  Healthy Start beneficiaries also receive free vitamins. 

The NHS Business Service Authority’s work to digitise the Healthy Start scheme is well underway and this will make it easier for families to apply for, receive and use Healthy Start benefits. Digitisation will replace the current paper application form, with an online application and replace the paper vouchers with a prepaid card.

I hope this information is helpful and demonstrates the range of action being taken to raise awareness and target action to prevent the risk of future tragic deaths such as that of Maya Zab.

Thank you for bringing these concerns to my attention.