Child Death

Concerns summary Staff failed to understand and address confirmation bias, hindering practice changes. Inadequate and slow training on this issue leaves mothers and babies at continued risk.

Concerns summary The lack of a designated referral pathway and national guidelines for achondroplasia means general paediatric teams are often unaware of associated sudden infant death risks, such as foramen magnum stenosis.

Concerns summary There are no national guidelines for monitoring and treating infants at risk of haemolytic disease of the newborn, especially regarding post-treatment and discharge care.

Concerns summary Haringey Children's Services facilitated a child's discharge into unsupervised parental care despite professional concerns, leading to fatal injuries before a planned safe placement could occur.

Concerns summary Group B Strep infection risks were not discussed during pregnancy, screening was not offered, and antibiotics were not administered, potentially contributing to the baby's death.

Concerns summary Lack of waterproof fetal heart rate monitoring equipment during birthing pool delivery, coupled with incorrect newborn resuscitation techniques by midwives and infrequent mandatory training, contributed to the death.

Concerns summary The Trust failed to maintain nurse training records, preventing assurance of competence, and neglected to create a formal care plan for a critically ill child, leading to disputed treatment.

Concerns summary Inexperienced police officers handled serious allegations, failing to seize evidence promptly or collaborate effectively with social services. Reliance on agency social workers, poor information sharing, and a lack of mechanisms for schools to receive assessment data further compromised child safeguarding.

Concerns summary Disjointed management and lack of identified consultants for a high-risk pregnancy led to poor continuity of care. Critical information about fetal inactivity went unreported and unheeded, causing a delay in necessary intervention.

Concerns summary GP and midwifery staff failed to seek urgent neurology guidance for a high-risk epileptic mother on anticonvulsant medication, resulting in inadequate management of fetal abnormality risks.

Concerns summary NHS 111 and Out of Hours services lack mandatory annual training for staff on paediatric symptoms, sufficient specialist clinical review, and clear guidance to default to ambulance calls for sick children.

Concerns summary Poor communication between midwifery and social work teams, undocumented calls, and delayed review of pathological CTGs contributed to missed opportunities for monitoring a vulnerable baby and identifying early sepsis.

Concerns summary A critically ill patient was taken to the A&E waiting area without visual assessment by reception or triage, missing crucial opportunities for early intervention and escalation of care.

Concerns summary A child was discharged after a prolonged seizure without sufficient observation, and neuroprotective strategies for potential hypoxic brain injury were not considered by the hospital.

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

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

Concerns summary The school's IT system lacked a mechanism to alert staff when students attempted to access blocked self-harm content, relying solely on teacher monitoring and risking missed safeguarding opportunities.

Concerns summary Key concerns include significant delays in discharge paperwork and specialist letters, unclear care responsibility, missing patient notes, inadequate instructions for community monitoring, and a lack of protocols for inter-hospital care transfers.

Concerns summary A dangerous diversion road with a history of fatalities lacked crucial 'single carriageway' warning signs, and sat navs directed drivers into the wrong lane, posing significant road safety risks.