Child Death

Concerns summary The current system allows inexperienced 17-year-old drivers to drive unsupervised with teenage passengers, which is a factor in collisions and increases the risk of future fatal incidents.

Concerns summary A lack of national guidelines exists for assessing paediatric heart conditions like myocarditis, coupled with insufficient awareness of Parvovirus. Locally, critical radiology reports were delayed, metabolic acidosis causes were not fully explored, and documentation of observations and handovers was incomplete.

Concerns summary A delay in obtaining adrenaline during resuscitation occurred due to non-standardised paediatric crash trolleys across hospitals, hindering junior doctors in a time-critical situation.

Concerns summary A national shortage of donor livers, particularly for "super urgent" children, is exacerbated by clinical guidance. This has led to extended waiting times, significantly increasing the risk of lives being lost due to organ unavailability.

Concerns summary NWAS failed to communicate significant ambulance delays to callers, even when a patient's condition deteriorated from Category 2 to 1. This lack of follow-up risks further deaths.

Concerns summary There is no nationally validated sepsis screening tool for Paediatric Emergency Departments, and the trust's own tool lacks consistent application between departments.

Concerns summary An unsecured ligature point was accessible, and emergency services faced difficult, treacherous access to the location, hindering timely intervention.

Concerns summary Mental health ward staff lacked neurodiversity training and were inexperienced, leading to insufficient staffing, missed patient observations, and incorrect medication charting.

Concerns summary A GP failed to provide specific advice on Candesartan risks during pregnancy, and the medication remained on repeat prescription, approved without review or system alerts, risking foetal harm.

Concerns summary A lack of national guidance for clinicians on considering and diagnosing Autoimmune Encephalitis creates a risk of missed diagnoses and future deaths.

Concerns summary A critical lack of national guidance exists for home births, covering midwife training, competency, staffing, equipment, and transfer thresholds, alongside an absence of outcome data collection.

Concerns summary Failures included not expediting Long QT Syndrome diagnosis, inadequate communication of expert opinion, a five-fold medication overdose, and a significant delay in recognizing and treating subsequent hypocalcaemia.

Concerns summary A lack of regulation, registration, and clear guidance for doulas creates confusion about their role, risks them working outside clinical boundaries, and poses challenges for midwives and patient care.

Concerns summary Two distinct triage systems for 999 and 111 calls create a two-tiered ambulance categorisation for similar urgent breathing complications, potentially delaying critical responses based on the system used.

Concerns summary There is a complete absence of regulation for Non-Therapeutic Male Circumcisions, including no requirements for training, accreditation, consent, record-keeping, infection control, or crucial aftercare.

Concerns summary The absence of a nationally validated sepsis screening tool for Paediatric Emergency Departments and inconsistent application of the trust's own tool across units risk delayed sepsis diagnosis.

Concerns summary The 'Essential Guide to feeding your Baby' is inadequate as it fails to explicitly warn against giving cow's milk to infants under one year due to the risk of anaemia.

Concerns summary Healthcare professionals failed to inquire about the contents of 'bottle-fed' milk and did not use interpreters for a non-English speaking mother, reflecting a lack of professional curiosity and adherence to guidance.

Concerns summary A critical communication breakdown between hospital and GP regarding medication monitoring, combined with repeated failures by GPs to check clinical records, left a child unprotected from fatal infection.

Concerns summary There is an absence of national guidance for the use of propofol for short-term sedation in children and young people in paediatric intensive care units.

Concerns summary Extensive and thick black mould in the property managed by Granddwell Estates poses a significant risk of future deaths.

Concerns summary Midwifery staff failed to elicit and act upon parental concerns about a baby's breathing and crying during postnatal contacts, leading to missed neonatal assessments and escalation.

Concerns summary Pathology protocols for suspected anaphylaxis need revision to ensure appropriate sample collection and retention. Police investigations of unexplained child deaths also lack procedures for seizing and retaining crucial scene evidence.

Concerns summary There are inadequate age restrictions on dangerous aerosol products and unclear warnings about instant death. Social media platforms also fail to take responsibility for harmful content promoting such misuse.

Concerns summary There is a lack of national guidance and relevant training for the increasingly common obstetric emergency of impacted fetal head during caesarean sections.