Child Death

Noted (AI summary) OPSS highlights industry led labelling initiatives to address risks. Officials will communicate the new industry labelling initiative to relevant groups to raise awareness. The Department highlights the Online Safety Act (OSA) which requires companies to prevent users from encountering illegal content and remove such content swiftly. Ofcom can issue information notices at the coroner's request, requiring services to provide data and Data Preservation Notices to preserve a child's data. BAMA has developed a new caution mark and statement that can be used to provide additional detail on the potential problems which can arise if the aerosol dispenser is not used in accordance with the manufacturer’s instructions. The caution mark will be placed in the top two-thirds of the back of the pack copy to ensure that it is noticed by the consumer. The Department for Culture, Media and Sport acknowledges the report and confirms that the Department for Science, Innovation and Technology (DSIT) leads on online safety.

Noted (AI summary) The team reviewed the MNSI report, process, and findings and concluded that their investigation process was correctly followed. A note has been added to their investigation record to highlight the findings of the inquest. The RCOG highlights the Scientific Impact Paper (SIP) number 73, second edition, which addresses impacted fetal head at caesarean birth and sets out detailed descriptions of safe technique. The ABC (Avoiding Brain Injury in Childbirth) programme incorporates these techniques and will be rolled out to maternity units in England as part of a national programme by NHSE.

Noted (AI summary) NHS Birmingham and Solihull acknowledges the concerns raised and will work with Black Country ICB to coordinate a single response. The ICB takes the recommendations seriously and is committed to support Black Country ICB and WMAS in delivering necessary improvements. West Midlands Ambulance Service has implemented several actions, including face-to-face mandatory refresher training for breech birth in 2026-2027, resumption of the e-PROMPT course, a Trust focus on learning and improvement of obstetric emergencies, and removal of out-of-date WMAS Maternity Action Cards from all Trust Vehicles. They have also issued a clinical notice to all staff to remove and destroy the out-of-date cards. AACE acknowledges the concerns and explains its role in providing advisory guidelines (JRCALC) for ambulance services. While AACE is not responsible for training, it has shared the report with relevant networks for consideration, noting variations in paramedic training for maternity care and breech birth.

Noted (AI summary) The Trust details the role of the GIC as detailed in the service specifications published by NHS England for Gender Identity Services for Adults (Non-Surgical Interventions) and states that it is working with NHS England and other providers to develop innovative ways of reducing the waiting times. NHS England is undertaking a review of adult Gender Dysphoria Clinics, with a report due in Autumn 2025 to inform a new service specification for 2025/26. They are also working to increase capacity in children and young people's gender services.

Noted (AI summary) • NHS England has produced a national framework and operational guidance for autism assessments. • The operational guidance suggests that Integrated Care Boards (ICBs) should ensure that all ages can access autism assessments. • Birchills Health Centre reviewed J.A’s case in a clinical meeting on 19.01.2023 and more recently on 02.02.2026 as part of their child protection meeting. • Birchills Health Centre identified that more comprehensive record keeping including clearer details of fluid intake should be recorded in assessing any child with risk of dehydration. • Birchills Health Centre had a presentation on identification of dehydration in children to help remind clinicians on most effective ways of assessing hydration status.

Noted (AI summary) The North East and North Cumbria Integrated Care Board acknowledges the concerns, noting the existing systems for patient record sharing via the Great North Care Record and the responsibility of medical professionals within multidisciplinary teams. They also refer to NHS England guidance on outpatient services. Moorbridge School has conducted a thorough review of their practices related to information sharing and safeguarding and will revisit and reinforce staff understanding of these policies through annual refresher training. 49 Marine Avenue GP Surgery acknowledges shortcomings and will strengthen communication with secondary care, improve multidisciplinary communication, and review safeguarding procedures. They will also implement new guidelines for monitoring, supporting families, and provide staff training in eating disorder management. The Trust has implemented a restructure within the Dietetics Service, introduced mandatory training for staff on safeguarding children, and will discuss information sharing between primary and secondary healthcare at the NENC GP Provider interface group by October 2025. The Department of Health and Social Care, and NHS England have programmes of work underway which should assist in preventing future deaths connected to this issue and aim to have a Single Patient Record processing information by 2028.

Noted (AI summary) RCEM highlights existing standards requiring paediatric early warning scores, results from national audits, involvement in designing a revised paediatric early warning score, and advocacy for better staffing and resources. The RCN states it is not the regulator for nurses and has no remit to address the concerns, but offers learning resources and highlights its work on the National Early Warning System (NEWS2) Observations Tracking Programme and collaboration with RCPCH on emergency care standards. The Trust has implemented training and induction enhancements, updated the Emergency Department Nurse in Charge checklist, mandated completion of an ED Paediatric Discharge Checklist, and is undertaking ongoing monitoring and training to improve standards of practice. The RCPCH is in the process of updating its Facing the Future Standards for Emergency Care, to be published later in 2025, which will clarify that observations are part of holistic care and repetition is dependent on the child’s well-being, alongside clarification around frequency of observations.

Noted (AI summary) NHS England acknowledges the concerns about the NHS Pathways algorithm and details its function. It highlights existing access to clinical support for health advisors and refers to work by the Regulation 28 Working Group. The practice has amended its process for new baby registrations, including removing the 'unregistered babies' folder and updating the Docman system to allow electronic rejection of incorrectly sent correspondence. The trust has already taken several actions including auditing the call, sharing learning through various channels, and providing training to staff. They have also reviewed and amended the NHS Pathways cardiac arrest algorithms following a previous case. The CQC contacted the provider, Unity Health, who confirmed they reviewed their processes and implemented a new system for creating a new profile when they are notified about a birth. They flagged this issue with the ICB and will be sharing details of this incident with the CQC’s Primary Care inspection teams.

Noted (AI summary) Resuscitation Council UK provides context on its neonatal resuscitation courses (NLS, OH-NLS, ARNI) and states that the NLS approach and algorithm adequately address the potential causes of non-response during newborn resuscitation. The Y&H Neonatal ODN has regional guidelines on surfactant administration and provides education sessions, and has written to all neonatal units in their network and other Neonatal ODNs to share these guidelines and draw attention to the Coroner's concerns. BAPM acknowledges concerns about LISA procedures and reversible causes of cardiac arrest, and while stating that universal consultant approval for LISA is not necessary, they plan to send a safety alert to members and stakeholders drawing attention to relevant recommendations in their Frameworks for practice. The Trust updated its risk register to include risks related to service provision, staffing, and protocols, and are working with the ODN and Commissioners. They also detail actions taken in response to the concerns raised, including changes to the SJUH designation and mitigations for risks due to lack of centralisation. RCPCH acknowledges concerns regarding LISA guidelines and reversible causes of cardiac arrest but defers to BAPM and RCUK for specific guidance and actions, noting they expect members to follow Resuscitation Council UK guidance. The Department acknowledges the concerns regarding maternity services at Leeds Teaching Hospitals NHS Trust, particularly staffing levels and the delay in centralizing services due to the New Hospital Programme's revised schedule, but defers to the Trust for specific responses and emphasizes existing duties for Trusts to maintain adequate staffing. This is an exhibit referenced by another response. It is a LISA checklist.