Child 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. 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). 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.

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) 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.

Noted (AI summary) CQC cannot regulate the care provided by Festimed Ltd at the event site, but can once the ambulance leaves the event. They note that Festimed Ltd went into voluntary liquidation and is no longer providing a service.

Noted (AI summary) The Department of Health and Social Care acknowledges the report and expresses condolences. They state that the Department of Education has oversight for child social care and is best placed to comment on the concerns raised. Social Work England acknowledges the coroner's concerns and is reviewing documentation and recordings from the inquest to determine if there are reasonable grounds to investigate any of the individual social worker’s actions, and will contact relevant parties to gather further information. The London Borough of Newham has re-evaluated internal policies and procedures and made significant changes and improvements, including a review of complaints, annual audits focusing on single parents with limited networks, and a review of the Supervision Policy, alongside MAGPIE and Praxis. An NRPF Plan template has been introduced following Child and Family Assessments, and the NRPF Panel Form has been embedded in their ICS system. NPAS will use footage from the incident as a case study/training tool to encourage Tactical Flight Officers to think beyond initial information in similar search scenarios, starting with the next training course on February 14th.

Noted (AI summary) The UKHMA engaged with stakeholders and communicated findings to members, and brought the MAIB report to the PMSC steering group. They also proposed the inclusion of guidance in the GTGP, which is expected to be reviewed around Q3 2024. The RYA has delayed review of its "Small High Speed Passenger Vessel Voluntary Code of Practice" awaiting MCA legislation, and envisages releasing a revised edition soon after the MCA Sport and Pleasure Vessel Code is finalized. British Marine helped produce and publish the HSPV code in 2010, revised in 2019, and made its use a requirement of membership for operators carrying out this type of activity. The BPA acknowledges the concerns and has corresponded with the MAIB regarding guidance, stating the MCA should lead this. The BPA has offered to promote and amplify guidance, but is not insured to set safety-critical guidelines itself. The Department for Transport states that the MCA is prioritising an updated Sport or Pleasure Vessel Code, currently under public consultation. The MCA has also been tasked to commission an anthropometric assessment of small high-speed passenger craft safety, with results expected in late spring/early summer 2026. The British Standards Institution acknowledges the concern regarding BS EN ISO 11591 but clarifies its role as a facilitator for expert committees to develop standards, not to interpret or regulate them; BSI will refer the concerns to the relevant technical committee. Associated British Ports acknowledges the concerns but states that monitoring AIS tracks of vessels and intervening in their operation would be very challenging, require dedicated resources, and may not materially increase the safety of harbour users, also noting the limitations of their powers and resources for policing vessels. The MCA is working on an updated Sport or Pleasure Vessel Code, informed by the MAIB Investigation Report, which is currently undergoing public consultation. They have also begun procurement for an anthropometric assessment of small high-speed passenger craft safety, with a report expected in late spring/early summer 2026 to inform future code revisions and guidance. The UKMPG states it supports information sharing but doesn't develop guidance and believes this should be led by the MCA. They will support actions suggested but this must be led by the MCA with industry input. Red Bay Boats Limited has instructed Scot Seats to test seats to meet HSC 2000 standards; they recommend installation of Scot Seats where possible; they will not accept any commissions in the thrill-seeking market; and feel that sea safari craft should not exceed 25 knots.

Noted (AI summary) The Royal College of Radiologists acknowledges the challenges of diagnosing retrocaecal appendicitis and advocates for prompt assessment by experienced clinicians, including expert surgeons and radiologists while highlighting radiology workforce shortages. It suggests early transfer to specialist centres where paediatric surgeons and radiologists are more available may be needed. The Royal College of Surgeons of England has shared the report with its Specialty Advisory Committee Chairs for consideration during upcoming curricula reviews. They are also exploring whether they can explicitly refer to retrocaecal appendicitis in the Care of the Critically Ill Surgical Patient (CCRISP) and the Clinical Skills in Emergency Surgery courses, and the case will be published as an educational vignette. The RCPCH will share information and suggestions for local improvement from the report with its paediatric members via its patient safety portal and the anonymised information within the report will also be shared for discussion with the RCPCH Clinical Quality in Practice Committee, where further actions may be identified. The RCGP expresses condolences and acknowledges concerns about diagnosing appendicitis, noting the diagnostic challenges of retrocaecal appendicitis and the limited availability of bedside ultrasound. They highlight existing NICE guidance and commit to supporting ongoing educational resources but do not describe specific actions.