Child Death

Noted (AI summary) NHS England is developing a Reasonable Adjustment Digital Flag to record information about patients, including if they are autistic or have a learning disability, and their reasonable adjustment needs. The RCEM highlights existing resources such as the Learning Disabilities Toolkit and involvement in the development of the ED version of the national paediatric early warning system (nPEWS). They feel unable to comment on inpatient care and state provision of learning disability nurses is outside their remit. CQC acknowledges the concerns but states that commenting on the specific guidance is outside of their regulatory scope. They are reviewing the case in line with their incident guidelines. The Trust is developing a Learning Disability Admission Checklist to provide prompts for staff in Emergency Departments and establish a system to record reasonable adjustments, planned for Quarter 3, 2025. RCPCH's revised Facing the Future: Emergency Care Standards will be published in Autumn 2025 and shared with relevant professionals, and will include a standard on EDs having a lead professional for CYP with complex needs and access to advice from a Learning Disability Liaison Nurse. The Department highlights the upcoming 10-Year Health Plan which will improve awareness of learning disability and autism within the health and social care system. It also references Martha's Rule which gives patients and their families the right to initiate a rapid review of their case.

Noted (AI summary) The RCOG expresses condolences and explains their guideline development process, stating that the Shoulder Dystocia guideline will be updated to include a section on alternative maneuvers but that there is not currently enough evidence to recommend the shoulder shrug maneuver. They emphasize the importance of effective training using existing recommended maneuvers.

Noted (AI summary) The Partnership acknowledges the concerns but cannot comment on the specific reasons for the original CDOP decision due to missing documentation. It provides assurance regarding the current child death review process, including improved data storage, family involvement, and panel operations. The Royal College of Radiologists acknowledges the concern, highlights the shortage of radiologists in the UK and the importance of written evaluations of imaging, and supports regional imaging networks to enable equitable access to expertise and resources. While willing to raise cardiac screening with England Boxing, the department is unable to provide additional funding. They highlighted existing support for Cardiac Risk in the Young through Sport England. The Royal College of Emergency Medicine acknowledges the concerns and provides context regarding the clinical management in the case. It references existing curriculum and resources related to the issues raised, but describes no specific actions taken or planned. The ICB will seek assurance of compliance with 'Shock to Survival' recommendations through Clinical Quality Review Meetings with relevant providers. It will also have access to GENOME dashboards to monitor patient safety surveillance and track progress against quality priorities. The Trust highlights several changes and quality improvements already made since the incident, including a new escalation process ('Martha's Rule'), a weekly meeting to discuss potentially harmed patients, and reviews by the CQC. All recommendations from previous Regulation 28 reports have been actioned. The Faculty of Intensive Care Medicine acknowledges the concerns, explains the role of focused echocardiography in intensive care, and highlights curriculum updates and guidelines supporting its use. They also express support for reliable provision of emergent echocardiography and image storage, but do not commit to specific actions. NHS England and the British Heart Foundation co-funded a sudden cardiac death pilot to develop mechanisms for post-mortem genetic testing, best practice pathways and engagement with patient groups. They also expect NHS Trusts to ensure protocols are appropriate in the wake of the death.

Noted (AI summary) NHS England discusses reports to prevent future deaths in a working group and escalates risks nationally through committees, referencing the Three year delivery plan for maternity and neonatal services and the Maternity and Neonatal Safety Improvement Programme. NHS Lancashire and South Cumbria ICB outlines measures in place to monitor compliance, including the reporting and escalation process and also that the North-West Regional Chief Midwife is developing Maternity Guidance and Principles with the aim to ensure there is a consistent approach in the identification and reporting of incidents. The Trust has reviewed practices, policies, and procedures, implemented mandatory training on candour, revised investigation processes, increased bereavement support, and implemented measures for consultant oversight. They also have enhanced incident review and executive oversight processes, including learning response leads. NHS Lancashire and South Cumbria ICB clarifies the independence and current availability of its Maternity and Neonatal Independent Senior Advocate role, noting it's under national evaluation and currently unable to accept new referrals.

Noted (AI summary) The RCOG acknowledges the coroner's concerns regarding the lack of guidance on managing abnormal antenatal CTGs, emphasizes the need for individualised care plans and refers to NHS England guidance on computerised CTG use. NICE acknowledges the coroner's concerns and will consider reviewing the evidence on antenatal CTG interpretation and actions, and will work with others to see if they can produce a practice guide to inform practitioners.

Noted (AI summary) RCEM acknowledges the concerns raised, referencing its guidance on staffing levels and track/trigger tools for children and adults in ED, noting that the national PEWS was designed for inpatient use and an ED version is being developed and tested. RCPCH notes that blood pressure is now included in the national PEWS. They are currently in the process of audit, review and revision and update of their current standards, to be published later in 2025. The Trust has updated its guideline so that all paediatric patients with persistent abnormal vital signs at the point of discharge, must be referred to Paediatrics prior to discharge and has consultants cover in place consistently from 09:00 to 23:00 (Monday to Friday).

Noted (AI summary) The Department for Transport acknowledges the coroner's concerns, highlights the falling number of fatalities for young drivers, and mentions the THINK! campaign and development of a new road safety strategy without committing to specific changes related to the concerns raised.

Noted (AI summary) NHS England acknowledges concerns about the death of Ella Murray, focusing on areas within its national policy remit, and will consider the ICB's response. It highlights the role of Integrated Care Systems and Provider Collaboratives and notes that the NHS England South East regional safeguarding team will have oversight of the ICB's actions. Key learnings will be shared across the NHS through the Regulation 28 Working Group. The Department of Health and Social Care expresses condolences and refers the coroner to NHS England, Kent and Medway Integrated Care Board, and the Department for Education for specific responses. The response outlines existing safeguarding duties, information sharing frameworks, and suicide prevention strategies, plus investment in mental health services.

Noted (AI summary) South Central Ambulance Service details actions taken since December 2023 including introducing the "Fit for the Future" programme, increasing paramedic apprenticeship numbers, reviewing skill levels of crews, increasing support for newly qualified paramedics, utilising specialist practitioners, implementing a new joint process with healthcare partners regarding ambulance crew wait times at hospitals and updating their fleet of vehicles. BT clarifies its procedures for handling emergency calls, including operator actions, listening practices, and the Critical Call Process, and explains that distress alone is not an agreed trigger for the Critical Control Process.

Noted (AI summary) Birmingham Womens and Childrens NHS Foundation Trust is reviewing the Trust’s Liver Biopsy Guidance with Microbiology colleagues regarding prophylactic antibiotics and creating an MDT of staff involved in procedures. They are also disseminating learning about haemothorax management and highlighting the importance of detailed documentation. The DHSC acknowledges the concerns raised in the report and explains the roles of NICE, NHS England and CQC in addressing them, noting that the hospital trust will respond separately to some points. It provides background on existing guidance and initiatives related to the concerns.