Child Death

PFD Category
Reports: 442 Areas: 65 Earliest: Jan 2015 Latest: 12 Mar 2026

77% response rate (above 62% average). 46% of classified responses show concrete action taken. Reports fell 2% from 57 (2023) to 56 (2024).

Response Status
Responded 341 No Response 8 Historic 83 Pending 9
AI Classification
Action Taken 46%
Action Planned 29%
Noted 19%
Disputed 7%
Based on 196 classified responses
Reports by Quarter
Clear
PFD Reports
290 results
Samuel Parkin
All Responded
2025-0361 18 Jan 2024 Inner West London
NHS England St George’s University Hospitals NHS Fo…
Concerns summary Hospital learning points from a child's death were not formally disseminated, and ultrasound reports gave false reassurance about malrotation due to poor understanding of USS limitations, delaying crucial diagnostic tests.
Iona Buckingham
All Responded
2024-0023 12 Jan 2024 Northamptonshire
NHS England NHS Northamptonshire Integrated Care Bo… Northampton General Hospitals NHS Trust
Concerns summary The hospital's inability to provide immediate paediatric x-rays and chest ultrasounds outside of limited hours poses a significant risk to children with deteriorating pneumonia or suspected pleural effusions.
Nuel-Junior Dzernjo
All Responded
2023-0530 18 Dec 2023 Suffolk
National Institute for Health and Care … Royal College of Paediatrics and Child …
Concerns summary A lack of clear guidance for prescribing intravenous Acyclovir, instead of ineffective oral medication, potentially led to incorrect treatment and preventable death for the patient.
William Gray
All Responded
2023-0511 8 Dec 2023 Essex
East of England Ambulance Service NHS T… Essex Partnership University NHS Founda… Department of Health and Social Care +2 more
Concerns summary Hospital doctors were unaware of JRCALC guidelines for adrenaline in life-threatening asthma. Ambulance guidelines lacked clarity on managing severe asthma attacks, and the trust's investigation failed to learn from repeat incidents.
Kyra Aslam
All Responded
2023-0498 5 Dec 2023 South Yorkshire (Western)
Sheffield Children’s NHS Foundation Tru…
Concerns summary A culture exists where medics may disregard parents' or nurses' views, and junior doctors are not adequately educated when consultants override their decisions, hindering learning.
Jonathan Goldstein, Hannah Goldstein and Saskia Goldstein
All Responded
2023-0514 5 Dec 2023 Inner South London
UK Civil Aviation Authority
Concerns summary A critical lack of compulsory mountain flying training and guidance for UK PPL(A) license holders means pilots undertake hazardous flights without adequate knowledge of specific risks and tactics.
Jennifer Whinney
All Responded
2023-0477 27 Nov 2023 Inner North London
Queens Hospital Royal London Hospital
Concerns summary Critical patient notes were not sent to an external appointment due to non-electronic records and a lack of clear responsibility for ensuring their transfer, risking incomplete medical history.
Madeleine Savory
All Responded
2023-0452 15 Nov 2023 Suffolk
NHS England
Concerns summary There is a national shortage of Tier 4 beds in paediatric mental health facilities, delaying timely access to crucial care for children in need.
Ocean-Leigh Hayes
All Responded
2023-0455 15 Nov 2023 South Wales Central
Cardiff and Vale University Health Board
Concerns summary Health visitors are inconsistently conducting physical reviews of sleeping arrangements for babies, missing opportunities to risk assess co-sleeping environments and advise parents on dangers.
Mason Williams
All Responded
2023-0442 10 Nov 2023 Warwickshire
Warwickshire County Council
Concerns summary Street lighting was unlit due to an underground cabling fault, likely from a previous collision. This lack of illumination along the road created a dangerous hazard for road users.
Luca Yates
All Responded
2023-0437 9 Nov 2023 Manchester South
Royal College of Paediatrics and Child …
Concerns summary Planned reductions in paediatric specialist training time in Level 3 Neonatal units risk future middle-grade and consultant general paediatricians having inadequate practical experience in neonatal resuscitation.
Alfie Mains-Forster
All Responded
2023-0459 9 Nov 2023 County Durham and Darlington
Clevermed Limited
Concerns summary The electronic risk assessment system (BadgerNet) at Royal Victoria Infirmary does not fully align with national guidance, hindering effective assessment. A critical updated risk chart (NEWTT2) remains unimplemented despite being overdue.
Karlton Donaghey
All Responded
2023-0399 23 Oct 2023 Newcastle upon Tyne and North Tyneside
Product Safety and Standards
Concerns summary Helium balloons are freely available without adequate warnings, and parents lack sufficient awareness of the significant risks they pose to young children.
Jessica Baker
All Responded
2023-0369 5 Oct 2023 Liverpool and Wirral
Department for Education Department for Transport
Concerns summary Concerns exist regarding the lack of clear government advice to schools on seatbelt use in commuter coaches and insufficient public information campaigns promoting seatbelt safety for children.
Riya Hirani
All Responded
2023-0339 15 Sep 2023 Inner North London
Department of Health and Social Care NHS England
Concerns summary A junior doctor failed to escalate care for a rapidly deteriorating child, dismissing a mother's accurate and persistent concerns. There was also no clear mechanism for families to obtain a second medical opinion.
Marcel Wochna
All Responded
2023-0332 14 Sep 2023 Hampshire, Portsmouth and Southampton
Hampshire & Isle of Wight Constubulary
Concerns summary Police staff lacked critical awareness of cold water shock, water rescue procedures, and the risks of handcuffing near water, alongside poor dissemination of relevant safety protocols.
Allison Aules
All Responded
2023-0313 30 Aug 2023 East London
Department of Health and Social Care NHS England Royal College of Psychiatrists
Concerns summary Under-resourced and underfunded CAMHS services, coupled with a lack of consultant leadership, led to significant delays in mental health assessments for children, despite rapidly increasing demand.
Lawson Bond
All Responded
2023-0335Deceased 22 Aug 2023 Worcestershire
Wychavon District Council
Concerns summary Worcestershire Regulatory Services' lack of proactive monitoring for unlicensed dog breeders on websites allows unscrupulous sellers to operate undetected, increasing the risk of dangerous puppies being sold to the public.
Juanita Nti
All Responded
2023-0301 18 Aug 2023 Inner South London
NHS England
Concerns summary Unclear morphine prescription details and an EMIS system lacking correct drug strengths led to a GP and pharmacist dispensing an incorrect, higher dose, resulting in a child's fatal overdose.
Louis Thorold
All Responded
2023-0311 18 Aug 2023 Cambridgeshire and Peterborough
Department for Transport Cambridge County Council
Concerns summary The self-certification process for driving licence renewal for drivers aged 70+, without independent medical scrutiny, risks allowing individuals with undiagnosed conditions like dementia to continue driving.
Devon Turner
All Responded
2023-0353 18 Aug 2023 Berkshire
Royal Berkshire NHS Foundation Trust Berkshire Integrated Care Board Medication and Healthcare Products Regu… +2 more
Concerns summary Unreliable and difficult-to-use home SATS machines, coupled with inadequate parent training on specific models, created a false sense of security and failed to alert parents to critical oxygen drops.
Rohan Godhania
All Responded
2023-0289 9 Aug 2023 Milton Keynes
NHS England and NHS Improvement Food Standards Agency
Concerns summary High protein supplements lack adequate warning labels for individuals with undiagnosed urea cycle disorders, risking severe medical emergencies due to sudden protein intake.
Leah Barber
All Responded
2023-0283 3 Aug 2023 West Yorkshire (Western)
City of Bradford Metropolitan District …
Concerns summary Bradford Council lacked a unified system for overseeing its involvement with vulnerable children, preventing learning from deaths and maintaining departmental disconnect, which risks future fatalities.
Finley May
All Responded
2023-0277 26 Jul 2023 East Riding and Hull
Royal College of Obstetricians and Gyna… NHS England
Concerns summary There is a need for increased awareness of complications associated with Keilland's forceps and guidance on maintaining skill levels or providing clear alternative methods if abandoned, to manage obstetric problems.
Elliott Harratt
All Responded
2023-0261 20 Jul 2023 Manchester South
Greater Manchester Integrated Care
Concerns summary Inadequate and inconsistent information provided to expectant mothers regarding sensitising events and when to call maternity triage increases the risk of Rhesus disease in newborn babies.