Child Death

PFD Category
Reports: 443 Areas: 65 Earliest: Jan 2015 Latest: 26 Mar 2026

79% response rate (above 63% average). 38% of classified responses show concrete action taken. Reports fell 2% from 57 (2023) to 56 (2024).

Response Status
Responded 352 No Response 5 Historic 85 Pending 1
AI Classification
Action Taken 38%
Action Planned 37%
Noted 24%
Disputed 2%
Based on 704 classified responses
Reports by Quarter
PFD Reports
443 results
Kobi Wright
All Responded
2020-0143 16 Jul 2020 Norfolk
James Paget University Hospital RadcliffesLeBrasseur LLP
Concerns summary (AI summary) No specific concerns were detailed in the provided text for this report.
Action Planned (AI summary) The Trust is reviewing its recruitment process for doctors to ensure appropriate training and induction, with changes to be implemented by the end of September 2020. The trust also describes existing processes for assessing locum doctors, offering substantive contracts after frequent employment, and encouraging staff to raise concerns. Dr. referred himself to the General Medical Council following the inquest. He has also been proactive in his efforts to improve his knowledge and partake in training for obstetric emergencies including completing the K2 Training Program.
Bethan Harris
All Responded
2020-0133 22 Jun 2020 West London
St. George’s University Hospitals NHS F…
Concerns summary (AI summary) Critical learning issues, including inadequate patient handover procedures for midwives, remained unaddressed a year after the death, with no specific training or effective reflective discussions implemented.
Action Taken (AI summary) The Trust has taken several steps including reinforcing the importance of accurate and contemporaneous record keeping, reviewing the administration of medication to patients, sharing learning, and ensuring patients are adequately monitored during their stay. Mandatory training will be ongoing.
Harrison Hassall
All Responded
2020-0111 12 May 2020 Leicester City and South Leicestershire
Department of Health and Social Care
Concerns summary (AI summary) Midwives are potentially deployed to community roles too soon after qualifying, lacking adequate experience, which is a concern for patient safety across the nation.
Action Taken (AI summary) The University Hospitals of Leicester NHS Trust and the East Midlands Ambulance Service NHS Trust have implemented recommendations for action resulting from investigations into the care provided, and the learning has been shared widely.
Theo Young
Partially Responded
2020-0094 20 Apr 2020 Surrey
Department of Health and Social Care East Surrey Hospital HSIB +1 more
Concerns summary (AI summary) Concerns were raised regarding the conduct, investigation, and conclusions made by the HSIB.
Disputed (AI summary) HSIB has made changes to its investigation methodology and processes to enable them to share early learning with Trusts following the investigation into Theo’s death. The Healthcare Safety Investigation Branch (HSIB) disputes the coroner's concerns, stating they provided opportunities for safety information to be shared and acted upon, and that inaccuracies were not due to their error. HSIB maintains its investigation was conducted in line with statutory directions. Surrey & Sussex Healthcare NHS Trust increased midwifery staffing, instituted daily staff allocation reviews, improved CTG monitoring and interpretation via training and audits, and recruited a Senior Lead Midwife. These actions led to an 'Outstanding' CQC rating in January 2019.
Ava-May Littleboy
All Responded
2020-0085 2 Apr 2020 Norfolk
British Standards Institution
Concerns summary (AI summary) Concerns exist regarding whether an appropriate operating or instruction manual was obtained for the inflatable trampoline, which exploded and caused a fatality.
Disputed (AI summary) The British Standards Institution (BSI) expresses its sympathy but states that it is not a regulatory or enforcement body and therefore cannot take action to prevent a reoccurrence. BSI states it would not be able to create a compulsory scheme to augment or replace that of ADIPS. Rundles disputes the coroner's concerns, arguing that their role as an inspection body does not extend to ensuring operators use equipment safely. They claim it is dangerous to divert responsibility from operators to inspection bodies. HSE has written to the Amusement Safety Device Council to remind them of their obligations and intends to publish additional guidance on the design, operation, and inspection of sealed inflatable devices, which is currently being drafted in consultation with representatives of the amusement industry.
Jordan Aira
Partially Responded
2020-0082 30 Mar 2020 Surrey
Department for Education Network Rail South Western Railway
Concerns summary (AI summary) Absence of physical barriers at platform ends, location of emergency phones near tracks, inadequate warning signs about live rail dangers, and lack of related education in the national curriculum create significant railway safety risks.
Noted (AI summary) SWR outlines existing signage at Ashford station and describes its participation in national campaigns and initiatives to raise awareness of railway safety and reduce trespassing. They do not consider further action is required, but will continue to engage with the wider rail group. Network Rail describes existing measures to prevent access to the railway tracks, including physical barriers and signage, as well as ongoing educational programs and safety campaigns. They have reduced overall trespass incidents by 24% and youth trespass by 32% in two years.
Sonny Parmar
All Responded
2020-0075 24 Mar 2020 London (North)
Barnet Council
Concerns summary (AI summary) There is no speed limit on the road adjacent to the school, failing to slow traffic during critical times when children are arriving and leaving the school.
Action Taken (AI summary) Barnet Council installed vehicle activated speed signs and renewed anti-skid surfacing near the crossing. They also programmed work to remove a dropped kerb and add guardrails, scheduled to commence 16 June 2020.
Rifky Grossberger
All Responded
2020-0070 11 Mar 2020 London Inner North
NHS England Royal College of Nursing
Concerns summary (AI summary) Insufficient communication of blind cord dangers to new parents, absence of a national safety leaflet, and missed opportunities for healthcare professionals to provide warnings contributed to the risk.
Noted (AI summary) NHS England highlights the existing advice available on the NHS Choices website and the role of Health Visitors in delivering the Healthy Child Programme. PHE aims to reduce preventable accidents as part of the national priority on Best Start in Life (2020-2025) through the modernisation of the Healthy Child Programme. The RCN has reviewed and strengthened its guidance about the potential risks of strangulation and suffocation on its clinical webpages for Health Visitors, Midwives, School Nurses, Children’s Nurses, Neonatal Nurses and General Practice Nurses. This matter has also been brought to the attention of members through Forums and social media platforms.
Jack Postle
All Responded
2020-0044 26 Feb 2020 Hertfordshire
Watford General Hospital
Concerns summary (AI summary) The maternity unit suffered from insufficient capacity for safe care, and consultant guidance inappropriately limited the availability of caesarean sections following failed inductions.
Action Planned (AI summary) West Hertfordshire Teaching Hospitals NHS Trust has developed a Prevention of Future Deaths Action Plan for 2020/21 including measures to improve the maternity pathway and is scoping the possibility of a three bedded induction bay on the current Delivery Suite.
Zachary Johnson
Historic (No Identified Response)
2020-0035 18 Feb 2020 Black Country
Walsall Healthcare NHS Trust
Concerns summary (AI summary) Lack of waterproof fetal heart rate monitoring equipment during birthing pool delivery, coupled with incorrect newborn resuscitation techniques by midwives and infrequent mandatory training, contributed to the death.
Marley Slack
All Responded
2020-0040 14 Feb 2020 Leicester City and South Leicestershire
Staffordshire, Shropshire and Black Cou…
Concerns summary (AI summary) The Red Book's prominent co-sleeping advice misleadingly omits the critical warning against co-sleeping with premature or low birth weight babies from its quick-reference "Don'ts" section.
Noted (AI summary) The document provides general guidance on safer sleep practices for newborns, focusing on recommendations for reducing the risk of sudden infant death syndrome (SIDS).
Benjamin Leonard
All Responded
2020-0032 7 Feb 2020 North Wales (East and Central)
Scout Association
Concerns summary (AI summary) The Scout Association failed to implement or ensure understanding of critical safety policies, including risk assessments and leadership oversight, for an organised trip, directly endangering young people.
Action Taken (AI summary) The Scout Association has made further changes and improvements to guidance, rules and systems described in a previous response, as a result of their ongoing review of safety in Scouting. They have also committed to considering all evidence from the inquest and conducting a Safety Incident Learning Inquiry.
Adam Bojelian
Historic (No Identified Response)
2020-0116 5 Feb 2020 West Yorkshire (East)
Leeds Teaching Hospitals NHS Trust
Concerns summary (AI summary) The Trust failed to maintain nurse training records, preventing assurance of competence, and neglected to create a formal care plan for a critically ill child, leading to disputed treatment.
Harry Richford
Partially Responded
2020-0117 3 Feb 2020 North East Kent
Department of Health and Social Care, N… The Chief Coroner
Concerns summary (AI summary) The provided text introduces the concept of "Concern 1" but does not detail any specific issues or findings.
Action Taken (AI summary) The Department of Health and Social Care outlined actions taken by health regulators and system partners to scrutinise and support the safety of maternity services at the East Kent Hospitals University NHS Foundation Trust, including a CQC inspection and engagement with families. They commissioned an independent review into maternity services at East Kent Hospitals.
Shneur Kaye
All Responded
2020-0013 17 Jan 2020 Manchester (North)
Bury Council
Concerns summary (AI summary) Safeguarding referrals were closed without parental contact, and referral information was not shared with other agencies due to data protection concerns. This practice potentially deprives social workers of vital context and undermines child protection.
Action Taken (AI summary) North Manchester Care Organisation outlines changes implemented after the incident, including revised discharge processes for children presenting to A&E with overdoses, new referral pathways for children with mental health needs, and mandatory safeguarding training for staff. Bury Council conducted a service review of the Multi Agency Safeguarding Hub (MASH) in early 2022, reinforcing strength-based practices and parental involvement unless safeguarding or legal reasons prevent it. The MASH also consults with referrers to clarify information and consider alternative support pathways.
Alice Sloman
All Responded
2019-0442 16 Dec 2019 Avon
Torbay and South Devon NHS Trust University Hospitals Bristol
Concerns summary (AI summary) Failure to refer a patient for a clinical geneticist's opinion, despite repeated parental requests and available services, led to a critical underlying condition remaining undiagnosed, resulting in premature death.
Action Planned (AI summary) Torbay and South Devon NHS Trust has discussed the case with relevant clinical teams and is implementing actions including: Paediatric clinicians learning about the Regional Genetic Service, Head of Regional Clinical Genetics Service attending a meeting with Paediatric clinical teams, twice yearly educational contact at clinical educational meetings, establishment of a regular advice point during/after the monthly clinics undertaken by the Regional Clinical Genetics Service in TSDFT. Bristol NHS Foundation Trust is working with Torbay and South Devon NHS Foundation Trust to finalise the Principles of Shared Care for Endocrine and has developed a patient information leaflet. It has been agreed that Service Levels Agreements will formalise the agreements in place with clear lines of accountability and responsibility.
Archie Spriggs
Partially Responded
2019-0405 2 Dec 2019 Shropshire, Telford & Wrekin
CAFCASS Shropshire Council Shropshire Safeguarding Children's Board +1 more
Concerns summary (AI summary) The concerns are covered within the 8 recommendations of the SCR regarding referral pathways, understanding of private law proceedings, notification processes for Section 37 reports, and engagement with multi-agency frontline staff.
Noted (AI summary) The Shropshire Safeguarding Partnership (SSP) acknowledges the report and states they are responsible for owning and governing delivery against the action plan related to the Serious Case Review, which was commissioned by the previous Shropshire Safeguarding Children’s Board (SSCB).
Katie Croft
Historic (No Identified Response)
2019-0393 19 Nov 2019 Manchester (South)
College of Policing Department for Education Department of Health and Social Care
Concerns summary (AI summary) Inexperienced police officers handled serious allegations, failing to seize evidence promptly or collaborate effectively with social services. Reliance on agency social workers, poor information sharing, and a lack of mechanisms for schools to receive assessment data further compromised child safeguarding.
Serena Nicholas
Historic (No Identified Response)
2019-0381 14 Nov 2019 West Yorkshire (East)
Hull University Teaching Hospitals NHS …
Concerns summary (AI summary) Disjointed management and lack of identified consultants for a high-risk pregnancy led to poor continuity of care. Critical information about fetal inactivity went unreported and unheeded, causing a delay in necessary intervention.
Hajra Sidat
All Responded
2019-0370 1 Nov 2019 Cheshire
Cheshire East Council Cheshire East Highways Department
Concerns summary (AI summary) The A34 bypass (Melrose Way Bend) is dangerous due to the lack of a continuous white line, allowing unsafe overtaking on a dark stretch of road.
Action Planned (AI summary) Cheshire East Highways has accepted the recommendation to replace the existing hazard centreline marking with a hatched hazard centreline on A34 Melrose Way, with works programmed to be carried out in March. • A road safety assessment report was prepared for A34 Melrose Way. • The existing centre line marking was replaced with a hatched hazard centreline and red surfacing in March 2020 to discourage overtaking. • These measures comply with national regulations and guidance.
Alex Malcolm
Partially Responded
2019-0344 15 Oct 2019 London Inner (South)
Department of Health and Social Care HM Prison & Probation Service MOJ
Concerns summary (AI summary) Insufficient Approved Premises, delays in making MARACs statutory, and difficulties recruiting probation officers due to low pay are systemic issues hindering efforts to prevent future deaths.
Action Taken (AI summary) HMPPS introduced a new pay structure in April 2018 for the National Probation Service, including a two-year pensionable pay award and a London Allowance and Market Forces Allowance to address recruitment and retention issues.
Amy Allan
All Responded
2019-0343 30 Sep 2019 London Inner (North)
Great Ormond Street Hospital NHS Trust
Concerns summary (AI summary) Critical information sharing failures between hospital departments, absence of pre-operative ECMO assessment and post-operative planning, conflicting extubation advice, and delayed ECMO commencement critically compromised patient care.
Action Taken (AI summary) Great Ormond Street Hospital has improved the spinal surgery pathway with intensive care and ECMO support, including ensuring relevant MDT members are involved in decisions, creating consultant-level handovers to ICU, and creating spinal CNS high-risk patient reminders. They also established a clear process for escalation to the ECMO team.
Kaiya Campbell
Historic (No Identified Response)
2019-0324 30 Sep 2019 Manchester (South)
King Street Medical Practice Tameside Clinical Commissioning Group
Concerns summary (AI summary) GP and midwifery staff failed to seek urgent neurology guidance for a high-risk epileptic mother on anticonvulsant medication, resulting in inadequate management of fetal abnormality risks.
Myla Deviren
Historic (No Identified Response)
2019-0311 24 Sep 2019 Cambridgeshire and Peterborough
Herts Urgent care Limited NHS 111 NHS Digital +1 more
Concerns summary (AI summary) NHS 111 and Out of Hours services lack mandatory annual training for staff on paediatric symptoms, sufficient specialist clinical review, and clear guidance to default to ambulance calls for sick children.
Caspian Thorn
Historic (No Identified Response)
2019-0305 19 Sep 2019 Manchester (South)
HSIB The Secretary of State for Health
Concerns summary (AI summary) Poor communication between midwifery and social work teams, undocumented calls, and delayed review of pathological CTGs contributed to missed opportunities for monitoring a vulnerable baby and identifying early sepsis.