(2sPansq From Jackie Doyle-Price MP Parliamentary Under Secretary of State for Mental Health and Inequalities Department Department of Health and Social Care of Health 39 Victoria Street London SW1H OEU Your reference: 8622/CH Our reference: PFD 1133566 RECEIVED 13 JUL 2018 ch Ms Alison Mutch OBE HM Senior Coroner; Manchester South Coroner' s Court Mount Tabor Street Stockport SKI 3AG July 2018 Ja k AukeL Thank you for your letter of 21 to the Secretary of State for Health and Social Care about the death of Carter Isaac Jepson. Iam responding as Minister with portfolio responsibility for women's health and maternity care. Your Report raises a matter of concern while not involving risk of future death; can clearly be a very distressing physical experience after the death ofa baby, and it is concerning to hear that you heard evidence at inquest that a lack of support might be a national issue. officials have sought advice on what guidance is available on the suppression of lactation following the loss of a baby, and the role of medication: Iam advised by the Medicines and Healthcare products Regulatory Authority (MHRA) that at present Bromocriptine and Cabergoline are licensed for the suppression of lactation for medical reasons and particular indications (such as when breast feeding is contraindicated due to medical reasons related to the mother or the new-bom) Bromocriptine is not recommended for the routine suppression of lactation or the relief of symptoms or post-partum and engorgement which can be adequately May that; My= pain

treated with non-pharmacological intervention (such as firm breast support; ice application) and/or simple analgesics. The NHS Specialist Pharmacy Service provides the following information; updated in April 2016,on these medications: These dopaminergic drugs are used for the treatment of specific pituitary and prolactin-mediated disorders, including galactorrhoea, hyperprolactinaemia and prolactinomas. are also used to suppress lactation by inhibiting prolactin secretion although symptoms of post-partum and engorgement can normally be adequately treated with simple analgesics and breast support. Although cabergoline is the only' licensed for routine suppression of lactation, its use is not usually recommended. Bromocriptine and quinagolide are off-label (unlicensed) for routine lactation suppression: Bromocriptine is not recommended as several cases of maternal seizures, stroke, psychiatric effects (including psychosis) and death been reported when used for suppression of lactation. This is supported by a 2014 EMA recommendation Cabergoline has not been associated with serious maternal adverse effects. Small, incremental doses may reduce, but not completely suppress lactation, although this cannot guaranteed Safety in Lactation: Bromocriptine and other dopaminergic published 2Oth 2012, updated 19th April 2016' The evidence therefore suggests that the medications may not fully suppress lactation and can be associated with significant side effects. Of key importance is that women should be given information about their choices for lactation suppression and be informed of the relative advantages and disadvantages of each approach: Non-pharmacological methods for lactation suppression are available to women and are covered in guidance, such as that published by the stillbirth and neonatal deaths https Lww sps nhs uklaricles salety-In-lactalion-bromocripting-and-other-dopaminergc-drugs They pain drug have be drugs, May

Department of Health charity, SANDS. Pregnancy Loss and the Death of a Baby , updated in 2016, is widely endorsed and recognised as setting out best practice in bereavement care. The guidance acknowledges that choices around lactation are deeply personal, and makes clear the importance of the provision of information and support to enable bereaved parents to make the choices that they feel are right for them Discomfort can be associated with non-pharmacological methods such as ice packs, analgesics and support bras However; there are measures that can be taken to reduce that discomfort such as warm showers; using cloths cooled with cold water; andlor gradual decrease in frequency of expression of milk Some women may choose to donate their milk to breast milk bank: The United Kingdom Association for Milk Banking provides support to healthcare professionals and bereaved mothers across the UK who are looking for information about donating milk . It is therefore for NHS trusts to ensure have in place comprehensive, compassionate guidance for bereavement care which includes the provision of information and support on lactation suppression, based on best practice and evidence: To support the NHS further in this regard, you will be interested to learn that the National Institute for Health and Care Excellence (NICE); is currently in the process of updating its guideline on postnatal care up to 8 weeks after birth and, after made aware of the concers in your Report; has decided to add the issue of suppression of lactation to the scope of the guideline. NICE expects to publish the final updated guidance in August 2020, though this date may be subject to change. I hope this information is helpful. Finally, the death of a child is a tragedy in any circumstance: You will be aware that all child deaths in England are required by law to be reviewed to learn lessons and to help prevent future deaths. We will shortly be publishing new statutory guidance on the process for child death reviews in England to ensure a uniform; high-standard of reviews locally and that each local area is able to capture learning that may be applicable at the national level. https ILwww sands Org uklabout-sandsImedia-centrelnews 2016.09 new-edition-sands-dlagship-publication- pregnancy-loss-and-Q http:Ilwww ukamb org/ https:I/www.nice org uklguidancelcg37 they` being

Each death is to be scrutinised by those involved in the care of the child; and from & broader independent and anonymised perspective at a Child Death Overview Panel. In addition to new statutory guidance, a national child mortality database has been commissioned by NHS England and is expected to become fully operational by Spring 2020. Through the database, the findings from reviews will be shared nationally and will enable learning aimed at saving children's lives. The database will support thematic learning and help the Department and its system partners to understand the causes of child mortality better and enable changes both locally, and nationally. The database is set to be the most extensive internationally, in that it is the first to cover the deaths of all children, from those who show a sign of life following birth through to their 18th birthday. Additionally, the database Will be aligned with the perinatal mortality review tool5 , in order to collect data the reviews of the circumstances and care leading up to and surrounding each stillbirth and neonatal death: hope the information [ have provided is helpful Thank YOu for bringing your concerns t0 our attention. JACKIE DOYLE-PRICE https: WWI npCu OX ac uklpmd from