Child Death

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) 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.

Noted (AI summary) NHS England highlights increased access to CYPMH services, with 758,000 children and young people receiving support in the 12 months to January 2024. They cite a 46% increase in the CYPMH workforce since January 2019 and mention the NHS Long Term Plan's ambition for 100% access to specialist support. They also note discussion of all PFD reports by a working group. The DHSC acknowledges concerns about long waiting times for assessment and treatment in children and young people’s mental health services, and the importance of early intervention and support. They highlight the government's plans to increase mental health staff and improve access to services, and state NHS England will address concerns about the “keeping in touch team”.

Noted (AI summary) NHS England expresses condolences and notes the concerns, but states that treatment for substance misuse is not within their remit. They highlight the Regulation 28 Working Group which shares learnings from preventable deaths across the NHS. The Department acknowledges concerns about residential and detoxification facilities for young people, but states that inpatient detoxification is rare and should be managed by community services with hospital support. They highlight existing funding and support for local authorities to improve drug and alcohol treatment, and will keep service models under review.

Noted (AI summary) The NMC is carrying out Fitness to Practise investigations, has shared the PFD report with the GMC, and will develop and publish a scenario to inform student midwives and midwives about hyponatraemia for the start of the next academic year. NHS Sussex confirms that University Hospitals Sussex NHS Foundation Trust (UHSx) and East Sussex Healthcare NHS Trust (ESHT) have implemented policies regarding fluid management and hyponatraemia in labour, developed and delivered training and education, and are auditing compliance with fluid balance charts. A leaflet has been developed advising mothers about fluid intake in early labour and shared learning about hyponatraemia and fluid balance in labour with the Regional Maternity Team at NHS England in 2022. The Royal College of Obstetricians and Gynaecologists expresses condolences and outlines its role in supporting maternity services through educational initiatives and clinical guidance. It refers to existing NICE guidelines and other resources related to fetal monitoring, intrapartum care, and hyponatremia, and suggests the Royal College of Midwives also be informed. The Department of Health and Social Care highlights the publication of an NHS Resolution report on hyponatremia and notes the rollout of the Brain Injury Reduction Programme across maternity units in England.

Noted (AI summary) The response consists of the organisation's name only.