Child Death

Concerns summary Insufficient training for community healthcare professionals in identifying infant heart defects, especially with maternal diabetes, and inadequate auditing of cardiac anomaly scans contribute to delayed diagnosis.

Concerns summary The absence of lifeguards at a dangerous breakwater during high-risk periods, despite historical effectiveness, and insufficient evidence that new deterrence measures are working, poses an ongoing risk.

Concerns summary Maternity services are unequally split with limited support and no on-site paediatric cover at one site. Concerns also include ambiguous unit classification and non-standardised guidelines for the LISA procedure and newborn cardiac arrest causes.

Concerns summary A&E had excessive waiting times and lacked timely medical triage, risking critical patient deterioration. Follow-up calls were made without full clinical information or clear advice, and essential patient results were not sent to the GP due to staff unfamiliarity with the process.

Concerns summary The neonatal investigation into the child's death was inadequate, failing to interview key staff and relying on incomplete records. Learning from the investigation was poorly shared and lacked context, hindering genuine organizational change.

Concerns summary Hospital patient information on induction was incomplete regarding risks of prolonged pregnancy, and midwives showed inconsistent understanding of escalating concerns for labouring mothers and CTG traces.

Concerns summary Private ambulance staff at a music event lacked adequate training for drug-affected patients and standard equipment, with unclear responsibility for pre-alert calls to hospitals for seriously unwell individuals.

Concerns summary The hospital lacked guidance for managing children with profound disabilities, failed to adequately consult or respond to their parents, and did not offer a Learning Disability Liaison Nurse, leading to poor care.

Concerns summary Clinicians frequently misinterpret ECGs and lack clear national guidance for paediatric exercise-induced syncope. The national asthma scoring system is insufficient, leading to misdiagnosis and missed cardiac conditions in children.

Concerns summary A child requiring 1:1 tracheostomy care died due to inadequate supervision and insufficient staffing, leading to a blocked tracheostomy. This represents a gross failure in care.

Concerns summary A successful obstetric manoeuvre, the "shoulder shrug," is not included in NICE guidelines despite its use abroad, indicating a potential omission for future guideline updates.

Concerns summary Key recommendations to improve cardiogenic shock care, including staff awareness, out-of-hours echocardiography access, and defined pathways, are not adequately funded or implemented across healthcare systems.

Concerns summary A GP surgery's care navigator lacked clear pathways and triage tools for urgent paediatric allergy referrals, leading to an inappropriate referral and no auditable record of the handling.

Concerns summary The Trust suffers from a deep-seated lack of candour, transparency, and deficient clinical governance, resulting in a failure to learn from past incidents, unreliable data, and inadequate reporting of serious harms.

Concerns summary Clinicians lack clear guidance on managing abnormal antenatal CTGs, specifically regarding decisions and timing of delivery, leading to inconsistent reliance on individual clinical judgment.

Concerns summary The emergency department was understaffed, leading to missed vital observations and delayed antibiotic administration. Inadequate staff training on adult onset asthma and ineffective safety netting advice contributed to the death.

Concerns summary There is a lack of guidance and regulation for children's contact sports, particularly for unofficial matches, leading to an absence of minimum standards for safeguarding, medical support, and risk management.

Concerns summary Inexperienced young drivers, recently passing their test, face increased accident risk when carrying young passengers, highlighting a concern about current regulations.

Concerns summary Nationally and locally, excessively long waiting times for Autism Spectrum Disorder (ASD) assessments delay crucial care and increase suicide risk, while local bridge safety measures fail to meet current guidance.

Concerns summary Changes in paediatric training removed compulsory direct observed training for neonatal intubation, increasing reliance on consultants and reducing future general paediatricians' experience in complex neonatal resuscitation.

Concerns summary A lack of national guidelines and standardized procedures for bone marrow aspirate and trephine biopsy, coupled with no database for recording outcomes, suggests inconsistent practice and missed learning.

Concerns summary Significant delays in connecting 999 calls to Emergency Call Takers and subsequent ambulance response times pose a risk, indicating a need for systems improvement in call handling.

Concerns summary Critical safety failures include schools breaching statutory swimming lesson duties, inadequate "no swimming" signage at open water, and poor placement of life-saving throw lines.

Concerns summary Routine corridor care in the emergency department impedes clinical assessment, delays ambulance handovers, and normalizes unsafe practices due to significant delays in discharging medically fit patients.

Concerns summary Lack of guidance for immunocompromised patient antibiotics, unclear trainee competence, and poor consent processes were evident. Inadequate learning from deaths and fragmented electronic records also led to missed patient risk factors.