Child Death

Concerns summary Parents of a child with Down Syndrome were not adequately informed of their child's increased infection risks, and routine chickenpox vaccination for this vulnerable group should be considered.

Concerns summary Critical failures include poor communication and transition between CAMHS and Adult Services for 16-18 year olds, leading to inappropriate out-of-hours treatment as adults. This includes placement in adult crisis units and unsupervised supported living post-assessment.

Concerns summary The serious incident analysis report was significantly delayed in being received by the coroner's office, hindering timely review and learning.

Concerns summary Jaundice in children beyond the neonatal period is under-recognised by doctors. Non-escalation to specialists can adversely affect care and be life-threatening, especially when organ transplantation may be critically needed.

Concerns summary Inaccurate and delayed care plans, poor communication between the school and catering service, and a failure to disseminate critical safety recommendations by the local authority resulted in inadequate allergy management for pupils.

Concerns summary Significant safety risks arose from a lack of formal health and safety training, absence of specific risk assessments for swimming pool birthday parties, and failures to follow safety procedures, including non-functional CCTV.

Concerns summary A lack of appropriate warning signage about water risks, especially with inflatables, and no lifeguard supervision contributed to the death in Roker Harbour.

Concerns summary A pothole exceeding the minimum depth for repair was present in the carriageway, contributing to a fatal accident.

Concerns summary Pedestrians waiting in hatched road areas and vehicles passing in these zones create confusion and significant risk of road traffic incidents.

Concerns summary There are no mandatory requirements for child participants in a Hunt to wear protective equipment, demonstrate competence, or have adult supervision with a specified ratio.

Concerns summary A school nurse's inadequate medication review process included using an incorrect allergy action plan, not verifying medication in school, and failing to ensure updated, in-date medication.

Concerns summary Inadequate handover procedures in the special care unit mean nurses may care for unfamiliar babies during breaks, highlighting a need for comprehensive handover covering all potential responsibilities.

Concerns summary There were failures to actively cross-check for shockable rhythms and to routinely use defibrillators in AED mode during cardiac arrest incidents, highlighting a need for improved staff training.

Concerns summary School procedures for unexplained absences were inadequate, with limited emergency contacts and delayed responses to non-attendance, revealing a need for wider adoption of immediate welfare checks.

Concerns summary The deceased's death from meningitis B could have been prevented by vaccination, highlighting an ongoing risk if the teenage group, which is at increased risk, is not included in the vaccination program.

Concerns summary Fragmented mental health services for young adults, with separate organizations and incompatible record systems, led to uncoordinated care, poor information sharing, and unclear responsibility during patient transfers in crisis.

Concerns summary Critical gaps exist in mandatory and assessed training for CTG tracing interpretation for both student and practicing midwives, leading to proficiency issues upon hospital recruitment.

Concerns summary Mental health services failed to adequately assess risk, record crucial details, or proactively engage with a vulnerable young person and her parents after an initial declined appointment.

Concerns summary Poor design of the school service road and bus bay, coupled with insufficient staff supervision, created a highly dangerous situation for children crossing the road, stemming from a lack of accountability in the school's construction.

Concerns summary Midwives and junior obstetricians demonstrated a critical lack of skill in interpreting abnormal cardiotocograph (CTG) traces. This highlights a systemic failure in CTG training and a need for mandatory competency testing for intrapartum care.

Concerns summary A mother's repeated requests for a Caesarean Section were not granted, leading to the baby's death and raising concerns about respecting maternal wishes in delivery.

Concerns summary Crib manufacturer failed to fully address the risk of death from an un-modified crib design, leaving a large number of potentially unsafe products in circulation with unaware customers.

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

Concerns summary The adolescent psychiatric unit lacked specific policies for managing self-harm risks from items, and emergency equipment did not include laryngoscopes, despite their prior successful use in airway obstructions.

Concerns summary Emergency services exhibited delayed and uncoordinated response, difficulty in pinpointing location, and failed to follow joint command protocols (JESIP), contributing to critical delays.