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).

Response Status
Responded 341 No Response 8 Historic 83 Pending 9
AI Classification
Action Taken 46%
Action Planned 29%
Noted 19%
Disputed 7%
Based on 196 classified responses
Reports by Quarter
PFD Reports
442 results
Emily Stokes
All Responded
2025-0372 19 May 2025 North East Kent
Kent Central Ambulance Service
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.
Action taken summary Kent Central Ambulance Service has implemented mandatory refresher training on drug overdose management, an enhanced clinical supervision framework, and updated pre-event risk assessment protocols. Th
Rose Harfleet
All Responded
2025-0223 13 May 2025 Surrey
Royal Surrey County Hospital NHS Founda… Royal College of Emergency Medicine Royal College of Paediatrics +3 more
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.
Action taken summary NHS England highlights that the Oliver McGowan Mandatory Training on Learning Disability and Autism has been required for all CQC-regulated providers since July 2022. They also published Health and Ca
Jake Lawler
All Responded
2025-0220 9 May 2025 Manchester South
Department of Health and Social 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.
Action taken summary The Department of Health and Social Care reports that NHS England is reviewing national guidance and has published guidance to support implementation of neighbourhood multidisciplinary teams for impro
Raihana Oluwadamilola Awolaja
All Responded
2025-0212 2 May 2025 Inner West London
Children’s Trust
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.
Action taken summary The Children's Trust has implemented mandatory training on monitoring and observation, introduced a floating staff role, and allocated dedicated administrative support. They also thoroughly reviewed i
Jannat Abbker
All Responded
2025-0203 25 Apr 2025 Inner North London
Royal College Obstetricians and Gynaeco…
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.
Action taken summary The RCOG has considered the evidence for the "shoulder shrug" manoeuvre but does not find sufficient evidence to recommend its inclusion in their RCOG management algorithm. Their Green Top Guideline i
Christian Hobbs
All Responded
2025-0176 7 Apr 2025 Cambridgeshire and Peterborough
Royal College of Emergency Medicine Royal College of Radiology Faculty of Intensive Care Medicine +5 more
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.
Action taken summary The Northamptonshire Safeguarding Children Partnership cannot comment on the specific historical CDOP review due to missing records, but assures that all CDOP forms and communications are now properly
Hailey Thompson
All Responded
2025-0171 4 Apr 2025 Manchester (West).
SSP HEALTH ASHTON MEDICAL PRACTICE WIGAN INTERGRATED CARE BOARD
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.
Action taken summary SSP Health and Ashton Medical Practice reinforced training for all staff regarding the correct process for child medication enquiries, ensuring pharmacists manage adult prescriptions only. They also n
Alexander Cardoza
All Responded
2025-0210 3 Apr 2025 City of London
Concerns summary Despite previous deaths, barriers at a specific location remain surmountable due to design flaws and insufficient operational security, including a lack of CCTV, posing an ongoing risk of falls.
Action taken summary The organisation has increased and enhanced security staffing. They plan further meetings to design and implement enhanced barriers for the roof terrace, permanently fix umbrella placements to deter c
Ida Lock
All Responded
2025-0155 21 Mar 2025 Lancashire & Blackburn with Darwen
Department of Health and Social Care University Hospitals of Morecambe Bay N… NHS Lancashire and South Cumbria Integr… +1 more
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.
Action taken summary NHS England has launched the Maternity and Neonatal Safety Investigation Programme, established regional governance structures, and published a Three-year delivery plan for maternity and neonatal serv
Alonzo Wood
All Responded
2025-0152 18 Mar 2025 West Sussex, Brighton and Hove
National Institute for Health and Care … Royal College of Obstetricians and Gyna…
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.
Action taken summary The RCOG acknowledges the concern but states that due to clinical variability, individualised care and professional judgment are essential, and there is no national guidance on antenatal CTG interpret
Billie Wicks
All Responded
2025-0146 17 Mar 2025 Inner North London
Royal College of Emergency Medicine Royal College of Paediatrics and Child … Royal Free Hospital
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.
Action taken summary The Royal College of Emergency Medicine clarifies existing guidelines and standards related to staffing and physiological observations, including that a new ED version of the national paediatric early
Alexander Eastwood
All Responded
2025-0142 14 Mar 2025 Manchester West
Department For Culture Department for Culture, Media and Sport
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.
Action taken summary The Department is exploring ways to urgently improve child safety in martial arts, including asking Sport England to work with stakeholders to ensure parents understand regulated vs. unregulated compe
William Radford
All Responded
2025-0143 14 Mar 2025 West Sussex, Brighton and Hove
Department for Transport
Concerns summary Inexperienced young drivers, recently passing their test, face increased accident risk when carrying young passengers, highlighting a concern about current regulations.
Action taken summary The Department for Transport states it is not considering Graduated Driving Licences but is tackling young driver risks through the existing THINK! campaign. The Department is also developing its firs
Joshua Weavers
All Responded
2025-0187 17 Feb 2025 Hertfordshire
NHS England Hertfordshire County Council Hertfordshire & West Essex Integrated C…
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.
Action taken summary NHS England has published the National Framework and Operational Guidance for Autism Assessment Services in April 2023, which was refreshed in 2025 to include further clinical guidance on managing wai
Yahya Hayat
All Responded
2025-0086 10 Feb 2025 Greater Manchester South
Royal College of Paediatrics and Child …
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.
Action taken summary The RCPCH explains that while mandatory direct observed training for neonatal intubation has been removed, key capabilities for airway management have been strengthened, aligning with evidence for non
Amelia Ridout
All Responded
2025-0077 7 Feb 2025 Cambridgeshire and Peterborough
National Institute for Health and Care … NHS England British Society for Haematology (BSH)
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.
Action taken summary NHS England states that developing clinical guidelines or a database for BMA and trephine biopsy does not sit within their remit. However, they commit to investigating evidence regarding training/supe
Ella Murray
Partially Responded
2025-0182 7 Feb 2025 Mid Kent and Medway
Department of Health and Social Care NHS England Kent and Medway Integrated Care Board
Concerns summary Failures in urgent safeguarding, lack of shared information access between health, social care, and education agencies, and an inability to convene urgent multi-agency meetings, meant a vulnerable child was left in an unsafe home environment.
Action taken summary NHS England explains its national policy remit, stating that local bodies like the Integrated Care Board will provide specific responses to the concerns regarding risk assessment and multi-agency work
Wyllow-Raine Swinburn
All Responded
2025-0064 3 Feb 2025 Oxfordshire
South Central Ambulance Service
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.
Action taken summary South Central Ambulance Service has implemented a 'Fit for the Future' programme, significantly increasing clinical staff, reviewing crew skill levels, and enhancing support for new paramedics. A new
Alex Crook
All Responded
2025-0062 30 Jan 2025 Manchester West
Wigan Metropolitan Borough Council
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.
Action taken summary Wigan Council is working with three schools to secure statutory swimming provision by end of academic year 2024/25, having secured funding for a Water Safety Education Officer. The Council has placed
Jackson Yeow
All Responded
2025-0032 17 Jan 2025 South Wales Central
Cwm Taf Morgannwg University Health Boa…
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.
Action taken summary Cwm Taf Morgannwg UHB has implemented multiple initiatives including the Optimise Programme, Discharge to Recover then Assess (D2RA) model, a Discharge Hub, and Safe2Start meetings. These measures aim
Aarav Chopra
All Responded
2025-0019 13 Jan 2025 Birmingham and Solihull
Department of Health & Social Care Birmingham Women’s and Children’s NHS F…
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.
Action taken summary Birmingham Women's and Children's NHS Foundation Trust has introduced a mandatory PALS course, a 'Consultant of the Week' model, and a Junior Doctor Induction Handbook, and has circulated new guidance
Ava Hodgkinson
All Responded
2025-0016 10 Jan 2025 Lancashire and Blackburn with Darwen
Department of Health and Social Care
Concerns summary Current pharmacy restrictions prevent pharmacists from issuing medication in a different strength, even if the correct dosage could be administered, causing dangerous delays in treatment.
Action taken summary The DHSC is exploring new flexibilities for pharmacists to dispense alternative medication strengths without an amended prescription in cases of immediate clinical need. They plan to launch a formal p
Eden Street
All Responded
2025-0017 10 Jan 2025 City of Kingston Upon Hull and the County of the East Riding of Yorkshire
Humber Teaching NHS Foundation Trust
Concerns summary Information from parents of autistic children via a helpline is not fed into weekly audit meetings, risking critical updates on deteriorating neurodiverse patients being missed by clinicians.
Action taken summary Humber Teaching NHS Foundation Trust disputes the systemic issue, stating the child referenced was not on their CAMHS waiting list and their system for handling contacts is robust. However, they are i
Eleanor Curley-Bennett
All Responded
2024-0705 20 Dec 2024 Staffordshire
Festimed
Concerns summary There was a critical lack of availability of essential medical equipment and adrenaline, which severely compromised the ability to provide emergency care.
Action taken summary The CQC states that care provided at events falls outside its regulatory remit and notes that Festimed Ltd went into voluntary liquidation. However, CQC has reviewed and updated its registration proce
Eleanor Aldred-Owen
All Responded
2024-0695 18 Dec 2024 Liverpool and Wirral
NHS England
Concerns summary The hospital's standard operating procedure for radiographers lacked provisions for escalating care or initiating urgent arrest calls when patients showed clear signs of imminent danger.
Action taken summary NHS England will share links to HCPC proficiency standards for radiographers on NHS Futures to remind staff of their responsibilities. They also note that Alder Hey Children’s NHS Foundation Trust has