Child Death

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.

Noted (AI summary) Surrey County Council is preparing a communication to all Surrey education providers to clarify that there is no financial threshold for requesting an EHCNA, reinforcing the statutory position under the Children and Families Act 2014. The Department for Education acknowledges the concerns, highlights existing guidance on safeguarding and EHCPs, and notes ongoing monitoring of Surrey County Council's SEND arrangements, keeping the safeguarding guidance under review.

Noted (AI summary) The Trust acknowledges the concerns raised and states that postnatal care was carried out within national guidance. They note that postnatal maternity wards are not conducive to rest and recuperation and that most mothers prefer to return home.

Noted (AI summary) NHS England outlines national standards for neonatal critical care units, references BAPM standards, notes NHS Trusts exercise their own policies for on-call response times, and states that University Hospitals Sussex NHS Foundation Trust and Sussex Health and Care Integrated Care Board have been engaged on the concerns raised in the report. The British Association of Perinatal Medicine (BAPM) will send out a safety alert to its members and stakeholders drawing attention to recommendations about consultant cover for neonatal units. University Hospitals Sussex acknowledges that current on-call arrangements do not meet BAPM standards and is exploring options for a separate Neonatal Consultant on-call rota for the Princess Royal Hospital. They are approaching the Integrated Care Board (ICB) to consider externally reviewing current arrangements.

Noted (AI summary) The DHSC refers to existing guidance on managing anaphylaxis in schools and the role of the Expert Advisory Group for Allergy, noting that adrenaline auto-injector suppliers were in stock at the time.

Noted (AI summary) NHS England is reviewing its communications approach to alerting GP practices about medicine shortages and the Pharmacy and Medicines Optimisation Team is reviewing the use of AAIs and their supply. All reports received are discussed by the Regulation 28 Working Group. BSACI is developing an online allergy education platform for healthcare professionals and others, covering anaphylaxis recognition and management. The BSACI allergy action plans include difficulty swallowing as a manifestation of anaphylaxis and state "if in doubt, give adrenaline." The RCP will work with other colleges and societies to agree and support standards of care and education related to allergy, including updating standards for allergy accreditation and promoting multidisciplinary care. As a member of the EAGA, the RCP is working on the development of the UK National Allergy Strategy. The GDC will write to NICE to suggest they review anaphylaxis symptoms and guidance for dental professionals, and will consider changes to CPD requirements regarding medical emergencies as part of a review concluding in 2025. The GPhC acknowledges supply issues with adrenaline autoinjectors and highlights existing standards for pharmacy professionals, signposting other resources for safe AAI use and directing medicine supply inquiries to the DHSC. They offer a meeting with Hannah's family. The RCPCH will share information from the report with its members via a patient safety portal and for discussion with the Clinical Quality in Practice Committee, where further actions may be identified.

Noted (AI summary) The RCEM expresses condolences and refers to existing guidance for re-attendance, paediatric emergency care standards, educational material on Group A Streptococcus, a Learning Disabilities toolkit, and the Oliver McGowan training programme. They state that questions about electronic patient records are best directed to NHS England. The RCPCH will share information and suggestions for local improvement from the coroner's report with its members via its patient safety portal and will discuss the report with the RCPCH Clinical Quality in Practice Committee to identify further actions. The Royal Free London Hospital has provided training on deteriorating conditions in children, including the use of the Paediatric Early Warning Score and sepsis identification tools, and has re-familiarised staff with the SBAR communication tool. A nurse champion has been appointed to lead training and audits and a pathway has been implemented to ensure reattendees are seen by the next available doctor.