Child Death

PFD Category

Reports: 442 Areas: 65 Earliest: Jan 2015 Latest: 12 Mar 2026

77% response rate (above 62% average). 46% of classified responses show concrete action taken. Reports fell 2% from 57 (2023) to 56 (2024).

Responded 341 No Response 9 Historic 83 Pending 8

Action Taken 46%

Action Planned 30%

Noted 18%

Disputed 6%

Based on 302 classified responses

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PFD Reports

290 results

Kian Gill

2015-0235 22 Jun 2015 Leicester City and South Leicestershire

Leicestershire County Council

Concerns summary Highway safety is compromised by overgrown hedgerows obscuring junction visibility, a lack of warning signage, and an uncurtailed national speed limit, creating collision risks.

Oliver Asante-Yeboah

2015-0201 27 May 2015 London Inner (North)

Care Quality Commission

Concerns summary Concerns were raised about the lack of formal regulation for non-medical providers of circumcision, a procedure considered surgical with increased infection risk in non-medical settings.

Baby Olsberg

2015-0177 7 May 2015 Manchester (North)

Royal College of Obstetricians Department of Health and Social Care Royal College of Paediatricians +1 more

Concerns summary Antenatal screening for Group B Streptococcus (GBS) and prophylactic intrapartum antibiotics for positive cases are not routinely offered by the NHS, potentially putting babies at risk.

Rasharn Williams

2015-0168 29 Apr 2015 London North (Inner)

Berger Primary School

Concerns summary The patient's care plan was unclear regarding emergency actions for breathlessness, potentially causing ambiguity for staff. A vital medical instruction notice for the child was also not displayed due to transitional arrangements.

Efan James

2015-0158 23 Apr 2015 Carmarthenshire & Pembrokeshire

Welsh Assembly Government

Concerns summary The Welsh Assembly Government's advice on reducing cot death is confusing, specifically regarding the ambiguous "very tired" criterion for parents considering bed-sharing.

Jack Rowe

2015-0154 22 Apr 2015 Wiltshire & Swindon

Communities & Local Government Department for Education Ministry of Housing

Concerns summary The absence of compulsory child-resistant fencing for private swimming pools in the UK, unlike other countries, creates a significant drowning risk for children.

Willow Davies

2015-0157 21 Apr 2015 Bedfordshire & Luton

Bedford Hospital NHS Trust

Concerns summary An inexperienced midwife was unsupported during delivery without prior resuscitation training, highlighting flaws in midwife allocation and the 'Supervisors of Midwives' support system.

Aleysha McLoughlin

2015-0136 8 Apr 2015 Manchester (West)

Communities & Local Government Ministry of Housing Department for Education +1 more

Concerns summary The training system for professionals working with young people regarding self-harm requires a comprehensive review, as self-harm is a growing public health crisis.

Bradley Griffiths

2015-0090 11 Mar 2015 Leicester (City & South)

Coventry and Warwickshire NHS Trust

Concerns summary Health visitor services failed to maintain contact and track a child after the mother moved without providing new GP or address details, leading to lost records.

Thor Dalhaug

2015-0063 6 Mar 2015 Lincolnshire (Central)

United Lincolnshire Hospitals NHS Trust

Concerns summary Failures included unsupervised surgeons, inappropriate techniques, incomplete medical records, and a lack of candour in disclosing circumstances surrounding a neonatal death, hindering investigation and causing distress.

Archie Hexall

2015-0081 5 Mar 2015 London (Inner South)

Lewisham and Greenwich NHS Trust

Concerns summary A communication breakdown between midwives led to critical information about a newborn's respiratory distress being lost, with temporary notes not retained and parents left uninformed.

Martha Seaward

2015-0033 2 Feb 2015 Norfolk

Norfolk County Council

Concerns summary An acknowledged dangerous bus stop on a busy road has seen no action taken on long-standing concerns and feasibility studies for safety improvements, despite previous warnings.

Isaac Nash

2015-0028 30 Jan 2015 North West Wales

Ynys Mon County Council

Concerns summary Strong and unpredictable currents in Aberffraw beach's river estuary pose a danger, as visitors lack local knowledge and there are no warning signs to inform them.

Carla London

2015-0003 6 Jan 2015 London (North)

Department of Health and Social Care

Concerns summary Concerns were raised about the need to consider NICE guidance on late-onset sepsis in premature babies and to research infection monitoring systems to improve early detection and treatment.

Syeda Fatima

2025-0613 Birmingham and Solihull

University Hospitals Birmingham NHS Fou…

Concerns summary Significant and systemic cultural tensions, including hierarchy and bullying, between midwifery and obstetric staff contributed to critical delays in patient care and decision-making.

Action taken summary The Trust has undertaken a comprehensive review and outlined key initiatives to address cultural and systemic issues in their maternity service. These include implementing twice-daily multidisciplinar