Child Death

Concerns summary There is a critical lack of clear public and professional safety guidance regarding the positioning and use of baby carriers/slings, particularly for breastfeeding, putting infants at risk of suffocation.

Concerns summary The National Police Air Service discounted a critical heat signature during a search. London Borough of Newham's child services demonstrated unprofessional, hostile behaviour, poor management, inadequate supervision, and substandard note-keeping, risking sub-optimal care for vulnerable individuals.

Concerns summary Inadequate assessment and communication of maternal risks led to delays in monitoring and expediting delivery. Poor communication and absence of policy between consultants during a time-critical spinal anaesthetic procedure also caused significant delays.

Concerns summary A newly qualified midwife was distracted by administrative tasks, missing critical CTG changes. The obstetric registrar failed to identify acute hypoxic injury due to reliance on historic data, and senior staff delayed emergency response despite prolonged abnormal CTG.

Concerns summary A lack of clear reporting requirements for section 10 exempt entities regarding adverse events prevents crucial findings from being shared with regulatory bodies, other trusts, or the wider industry.

Concerns summary Inconsistent regulations for high-speed RIB operations, inadequate craft design for passenger safety, poor forward visibility, and insufficient risk management systems contribute to serious impact and vibration injuries. Licensing arrangements and interim safety measures are needed.

Concerns summary A vulnerable child presenting to the Emergency Department after self-harm missed crucial early mental health intervention due to the failure to apply established NICE guidelines and local policy for comprehensive assessment.

Concerns summary Multiple doctors failed to diagnose appendicitis in a child. Concerns include a lack of readily available bedside ultrasound and inadequate medical training in considering this diagnosis for abdominal pain.

Concerns summary The college safeguarding team lacked awareness of a student discontinuing external mental health support, indicating a critical communication breakdown between the college and mental health organizations.

Concerns summary A widespread misconception among schools that £6,000 must be spent on a child's SEN before an EHCP assessment application is delaying critical early support, increasing the risk of mental health issues and suicidality.

Concerns summary Insufficient in-county psychiatric inpatient beds for children persist, with new units inadequate for demand or specific needs. A new suicide risk assessment system lacks clear alerts on medical records, risking clinicians missing vital information.

Concerns summary An exhausted mother was discharged too soon, only 4 hours post-delivery after a prolonged labour, leading to the baby's death when she fell asleep during breastfeeding. This raises concerns about the timing of postpartum discharges.

Concerns summary A company's risk assessment dismissed lifeguards as impractical, yet a safety officer found compliance borderline and noted other similar venues employed them. Concerns exist that lessons about pool safety and the necessity of lifeguards have not been learned.

Concerns summary Neonatology Consultants are not immediately on-site overnight or weekends at two distant hospitals, and variable response times due to travel constraints pose a risk in emergencies.

Concerns summary The car's gear selection design, lacking an intermediary step beyond a button press, contributed to driver error, raising concerns about vehicle safety features.

Concerns summary Dental staff failed to recognise anaphylaxis symptoms, and allergy plans gave false reassurance for mild reactions. Education is needed on identifying anaphylaxis and using adrenaline auto-injectors if in doubt.

Concerns summary Insufficient consideration for managing anaphylaxis risk during school commutes highlights a need for better education for schools, patients, and parents on the importance of carrying adrenaline auto-injectors.

Concerns summary A distressed neurodiverse child did not receive full observations for over four hours in a busy emergency department, leading to a catastrophic cardiovascular compromise and highlighting challenges in assessing such patients.

Concerns summary Peabody Housing Association failed to address an unsafe canal barrier, demonstrating a lack of boundary knowledge, neglected risk assessments, ignored resident complaints, and inaction on known safety hazards.

Concerns summary Inadequate regulation of transport for Special Educational Needs children led to issues including crew unfamiliarity with safety plans, poor handovers, insufficient personnel change notifications, and a lack of mandatory training or oversight.

Concerns summary A busy road intersecting a well-used pedestrian track lacks adequate warnings for both drivers and pedestrians, and there are no measures to prevent pedestrians walking into traffic or to allow safe crossing.

Concerns summary An ineffective verbal-only handover, incompatible IT systems, and high A&E acuity caused critical clinical information to be missed. A lack of national handover protocols for emergency departments exacerbated this risk.

Concerns summary A culture within midwifery led to delayed action and an assumption of benign causes for antepartum haemorrhage (APH), with established guidance not followed, representing a regional and potentially national concern.

Concerns summary A critical lack of awareness among general paediatricians regarding rhabdomyolysis, a rare but serious condition in young children, risks missed diagnoses and fatal outcomes.