Child Death

Concerns summary Serious fractures and head injuries sustained in a road traffic collision were critically overlooked when the deceased attended the hospital.

Concerns summary Local Authorities with high numbers of young people in care lack sufficient resources and qualified staff, further compounded by poor integration between care, mental health, and educational support services.

Concerns summary Lack of early intervention mental health support for young people not meeting CAMHS thresholds, coupled with poor information sharing between health agencies and the removal of medically qualified staff in schools, hindered comprehensive care.

Concerns summary Lack of national sharing for improved Induction of Labour processes, insufficient guidance on prolonged reduced fetal movement, and failure to advise a mother to return for further monitoring for ongoing concerns were identified.

Concerns summary Critical issues include a lack of continuity in antenatal care, insufficient safe-sleeping advice provided post-natally, and midwives' unawareness of criminal implications of infant overlay with alcohol/drugs.

Concerns summary A critical lack of national oversight and guidance for private landlords on updated blind cord safety regulations means many are unaware of risks from older blinds, leading to child strangulation deaths.

Concerns summary A lack of integrated care, an overarching supportive plan, and poor information sharing between health professionals on discharge led to an uncoordinated approach for a child with complex needs. Inconsistent understanding of protocols and the "red book" exacerbated these issues.

Concerns summary The lack of a national screening program for streptococcal infection in labouring women misses opportunities to detect and treat infections like chorioamnionitis in infants.

Concerns summary NHS Pathways for 111 call handlers failed to adequately recognize acutely unwell children due to missing questions (e.g., cold hands/feet) and inappropriately high thresholds for symptoms like green vomit.

Concerns summary The inability to store sequential scan data and provide sonographer alerts hindered comparison and further investigation, potentially delaying necessary changes to patient care plans.

Concerns summary The CAMHS/GP referral form is inadequate, resulting in insufficient information for risk assessment and delayed care; the Trust should reconsider redesigning the form.

Concerns summary The approximate age of moped riders was not communicated to the police tactical team, omitting a relevant factor for risk assessment and decision-making.

Concerns summary A dysfunctional team exhibited unclear clinical leadership, poor CTG interpretation and communication, inadequate record-keeping, and insufficient staffing, with junior staff unable to challenge decisions.

Concerns summary Systemic failures in allergy management included poor understanding by pupils and staff, unchecked medication, non-standardised action plans, and inadequate awareness of critical EpiPen administration protocols.

Concerns summary NHS 111 pathways use unsuitable language for children and cause confusion, while GP surgeries experience delays in uploading 111 notes. There is also a lack of standardized lipase/amylase testing for children and inconsistent ED return patient reviews.

Concerns summary The absence of a defibrillator at Marshalls Arts College poses a critical safety concern.

Concerns summary School friends were aware of the deceased's increasing suicidal ideation and methods explored online but failed to report it to adults, partly due to fear of device bans.

Concerns summary No specific concerns were detailed in the provided text.

Concerns summary The inability to trace a doctor who left the UK after treating a patient compromised the investigation and prevented the clinician from learning from issues raised.

Concerns summary A critical gap exists in urgent mental health services for 16 and 17-year-olds in Sheffield, with necessary additional resources for CAMHS lacking guaranteed funding.

Concerns summary Systemic failures in record-keeping, including incomplete electronic records and delayed disclosure, were evident. Inadequate communication with external agencies like GPs and schools further compromised patient care and information sharing.

Concerns summary The absence of facilitated pedestrian crossing points and sparse crossing infrastructure in a busy area, combined with poor street lighting, creates a significant hazard for pedestrians.

Concerns summary Maternity services suffered from an incomplete action plan, institutional stress from a merger, a culture of not performing essential procedures at night, poor information sharing, insufficient staffing, and a lack of leadership.

Concerns summary Fragmented asthma care lacked coordinated records, long-term management plans, and guideline adherence, resulting in missed risk factors, excessive medication, and no clear clinical responsibility.

Concerns summary Multi-purpose nursing pillows lack specific safety regulations and have inconsistent, often misleading, warning labels that are easily lost, promoting unsafe sleep practices for infants.