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 9 Historic 83 Pending 8
AI Classification
Action Taken 46%
Action Planned 29%
Noted 19%
Disputed 7%
Based on 196 classified responses
Reports by Quarter
PFD Reports
442 results
Lucas Pollard
All Responded
2024-0058 1 Feb 2024 Bedfordshire and Luton
East of England Ambulance Service
Concerns summary A Critical Care Team was not immediately dispatched, and an End Of Shift Policy was inappropriately applied, preventing a rapid response vehicle deployment, despite clear evidence of patient deterioration.
Christopher Kapessa
All Responded
2024-0039 25 Jan 2024 South Wales Central
Coal Authority
Concerns summary The Coal Authority lacked accessible risk information, specific water safety policies, and effective inspection protocols, failing to address deep, fast-flowing water dangers and implement identified safety works.
Samuel Parkin
All Responded
2025-0361 18 Jan 2024 Inner West London
St George’s University Hospitals NHS Fo… NHS England
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
Northampton General Hospitals NHS Trust NHS England NHS Northamptonshire Integrated Care Bo…
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
Royal College of Paediatrics and Child … National Institute for Health and Care …
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
Association of Ambulance Chief Executiv… Department of Health and Social Care East of England Ambulance Service NHS T… +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
Royal London Hospital Queens 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.
Boycie Chatterton
Historic (No Identified Response)
2023-0483 27 Nov 2023 Inner West London
Department of Health and Social Care NHS England
Concerns summary The absence of a properly managed and funded national register for Tracheo-Oesophageal Fistula (TOF) cases likely hinders improved outcomes and survival rates.
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.
Tyler Ryan
Partially Responded
2023-0395 17 Oct 2023 Newcastle upon Tyne and North Tyneside
General Medical Council Royal College of Pathologists Department of Health and Social Care +1 more
Concerns summary A chronic national shortage of Paediatric Pathologists causes significant delays in reports, hindering timely genetic testing for families and preventing future deaths. Greater use of molecular autopsy is needed.
Adam Stuyvesant
Historic (No Identified Response)
2023-0372 6 Oct 2023 Wiltshire and Swindon
Great Western Hospital
Concerns summary The Emergency Department's DVT risk assessment failed to consider lower limb immobility from plastic boots, risking patients not receiving crucial anti-clotting medication and developing fatal pulmonary embolisms.
Jessica Baker
All Responded
2023-0369 5 Oct 2023 Liverpool and Wirral
Department for Transport Department for Education
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.
Leighton Dickens
Historic (No Identified Response)
2023-0367 29 Sep 2023 South Wales Central
South Wales Police
Concerns summary Police officers have limited access to qualified mental health advice and clinical records when responding to mental health crises, as urgent support teams are not readily available and a promised service is unimplemented.
Sienna Monterio
Historic (No Identified Response)
2023-0344 16 Sep 2023 Blackpool & Fylde
Royal College of Paediatrics and Child … National Institution for Health and Car… Royal College of Obstetricians and Gyna…
Concerns summary A lack of national standardisation means blood gas analysers in neonatal resuscitation settings often fail to analyse haemoglobin levels, hindering critical decision-making and risking preventable infant deaths.
Eclipse Morrison
Historic (No Identified Response)
2023-0334 15 Sep 2023 Warwickshire
George Eliot Hospital NHS Trust National Institute for Health and Care … Royal College of Obstetricians and Gyna… +2 more
Concerns summary Policies for high-risk pregnancies were not followed, leading to a failure to consider elective Caesarean Section. There's inadequate training and assessment for junior and locum doctors on identifying serious risk factors.
Riya Hirani
All Responded
2023-0339 15 Sep 2023 Inner North London
NHS England Department of Health and Social Care
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.
Isabela Suciu
Partially Responded
2023-0326 12 Sep 2023 Inner South London
British Association Perinatal Medicine Queen Elizabeth Hospital Trust NHS England +1 more
Concerns summary Conflicting guidelines for newborn hypothermia led to delayed antibiotic administration and create ongoing confusion and risk of missed clinical signs in neonatal units.