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

442 results

Thomas Beaty

Partially Responded

2015-0130 31 Mar 2015 Manchester (North)

Department of Health and Social Care Royal College of Obstetricians and Gyna… Pennine Acute Hospitals NHS Trust

Concerns summary Ambiguous national instrumental delivery guidance and misaligned trust protocols, particularly concerning procedure abandonment criteria and traction terminology, created risks during childbirth.

Elliott Bignall

Historic (No Identified Response)

2015-0111 23 Mar 2015 West Sussex

Concerns summary The railway foot crossing was poorly lit with inadequate signage, posing a danger to pedestrians who might not see or hear approaching high-speed trains, especially if distracted.

Robbie Williamson

Historic (No Identified Response)

2015-0105 12 Mar 2015 Lancashire (East)

Association of Independent Gas Transpor… Scotia Gas Network Northern Gas Network +1 more

Concerns summary Concerns exist regarding exposed, raised pipework, potentially attached to bridges, that is accessible to the public and may pose a safety risk.

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.

Daniel Strickland

Historic (No Identified Response)

2015-0505 20 Feb 2015 Southampton and the New Forest

St Edward’s School

Concerns summary Deficient information management included a lack of written handovers, inaccurate logs, an inaccessible daily log, and no clear method for sharing critical medical information with external parties.

Lexie Harrison

Partially Responded

2015-0070 20 Feb 2015 West Yorkshire (East)

British Society of Paediatric Gastroent… Sheffield Children’s NHS Foundation Tru… Leeds Teaching Hospitals NHS Trust

Concerns summary A critical lack of national and local standardised policies for paediatric oesophageal varix banding procedures leads to inconsistent consultant practices. This impacts patient assessment, post-procedure care, and bleeding management.

Mohammed Yousaf

Historic (No Identified Response)

2015-0056 16 Feb 2015 Manchester (North)

Pennine Acute Hospitals NHS Trust Royal College of Obstetricians and Gyna… Department of Health and Social Care

Concerns summary There are no national guidelines for interpreting antenatal CTG tracings. Additionally, the Trust's Interpreting Policy faced issues with dissemination, application, and applicability, particularly concerning informed consent.

Shannon Gee

Historic (No Identified Response)

2015-0039 3 Feb 2015 Cornwall

Kernow Clinical Commissioning Group Department of Health and Social Care

Concerns summary Delays in mental health treatment occurred due to unaddressed gaps between organisational treatment thresholds and difficulties transferring medical notes, raising concerns about seamless patient care.

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.

Sian Armstrong

Historic (No Identified Response)

2015-0019 21 Jan 2015 Avon

North Bristol NHS Trust

Concerns summary A significant delay occurred in providing Cognitive Behavioural Therapy (CBT) for a child, Sian Armstrong, who was assessed as needing it, highlighting a lack of timely access to critical mental health support.

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.

Samantha Gould and Christine Gould

2021-0184 Cambridgeshire and Peterborough

Concerns summary Police lacked follow-up with clinicians/parents and failed to inform mentally ill child abuse victims about their option to provide evidence later. There was no guidance for police on communicating with such vulnerable minors.

Action taken summary The Trust acknowledges the ongoing need for a 24/7 home treatment service, progressing this at an ICS level and submitting a business case for funding. It will remind doctors of ICD-11 changes regardi

Poppy Harris

2021-0352 Milton Keynes

Concerns summary Lack of a birth plan for the mother and the use of Kielland’s forceps, which resulted in a catastrophic spinal cord injury, highlight concerns about birthing practices.

Action taken summary Milton Keynes University Hospital has implemented an electronic health record system that includes a birth preferences section for midwives to complete with patients, and plans to audit documentation

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