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
Clear
PFD Reports
290 results
Phoenix Chapman
All Responded
2023-0246 14 Jul 2023 Inner North London
Homerton Healthcare NHS Foundation Trust
Concerns summary A lack of shared understanding and communication breakdown among hospital clinicians regarding protocols for high-risk unplanned home deliveries, particularly between obstetricians and midwives, hindered effective care.
Mustafa Nadeem
All Responded
2023-0237 11 Jul 2023 Birmingham and Solihull
Department for Transport West Midlands Combined Authority Collaborative Mobility UK
Concerns summary Children easily bypassed age and licence checks to illegally use hire e-scooters, facilitated by inadequate identity verification and payment system vulnerabilities. Limited regulation and ineffective education exacerbate this risk.
Sinon Masha
All Responded
2023-0228 30 Jun 2023 Birmingham and Solihull
University Hospitals of Birmingham NHS …
Concerns summary The hospital's multiprofessional appointment system for high-risk home births is not functioning as per guidance, resulting in fragmented communication and depriving patients of crucial collective professional perspectives, risking lives.
Mason French
All Responded
2023-0208 22 Jun 2023 Sunderland
South Tyneside Council
Concerns summary Despite previous safety improvements, cyclists remain at significant risk at a specific road location, necessitating further measures to prevent future collisions.
Amelia Barbosa
All Responded
2023-0167 19 May 2023 Cambridgeshire and Peterborough
North West Anglia NHS Foundation Trust
Concerns summary Inadequate training means midwives still take inaccurate cord blood samples, leading to false reassurances. There is also a lack of training on UVC/IO access and blood transfusions for neonatal resuscitation.
James Philliskirk
All Responded
2023-0376 10 May 2023 South Yorkshire (Western)
Sheffield Children’s NHS Foundation Tru…
Concerns summary Junior staff failed to escalate concerns, exacerbated by unclear guidance on chickenpox reinfection, confirmation bias, and inadequate assessment of skin lesions. GP referrals were also not given sufficient weight, delaying crucial treatment.
Mojeri Adeleye
All Responded
2025-0401 10 May 2023 South Yorkshire (West District)
Sheffield Teaching Hospitals NHS Founda…
Concerns summary There was a lack of regard for the mother's pregnancy knowledge and insufficient discussion with parents about potential measures for premature labour before 22 weeks.
Sienna Barber
All Responded
2024-0062 3 May 2023 Manchester North
Department of Health and Social Care Royal College of Paediatrics and Child … National Institute for Health and Care …
Concerns summary Lack of national guidance for diagnosing and treating Group A Streptococcus, particularly for high-risk groups like children under 5, and the absence of rapid antigen testing for under 5s, creates diagnostic delays.
Milan Hamza
All Responded
2023-0142 27 Apr 2023 Cambridgeshire and Peterborough
Cambridgeshire County Council
Concerns summary Lack of adequate signage to alert westbound drivers of a sharp left-hand bend and the adjacent water hazard creates a significant risk of future road incidents.
Samuel Howes
All Responded
2023-0133 24 Apr 2023 South London
Department of Health and Social Care NHS England
Chester Mossop
All Responded
2023-0127 20 Apr 2023 Cumbria
Office of Product Safety and Standards
Concerns summary Bath seats create a false sense of security for parents, despite not being safety devices. There is a concerning lack of national advice to healthcare professionals and parents regarding their safe use.
Kyron Hibbert
All Responded
2023-0077Deceased 27 Feb 2023 Bedfordshire and Luton
Forest of Marston Vale Trust
Concerns summary The Trust failed to address known drowning risks at a lake, with inadequate supervision, missing water depth warnings, and inaccessible life-saving equipment.
Katie Wilkins
All Responded
2023-0041Deceased 26 Feb 2023 Liverpool and Wirral
Department of Health and Social Care
Concerns summary Oncology consultants inappropriately lead care for APML patients, where significant bleeding risks require haematologist expertise, exacerbated by a national shortage of specialists.
Molly-Ann Sergeant
All Responded
2023-0078Deceased 19 Feb 2023 Essex
Essex Partnership NHS Foundation Trust …
Concerns summary Deficient discharge planning for a child with delayed autism diagnosis and high suicide risk stemmed from insufficient assessment, poor council response to referrals, and a lack of understanding of Mental Health Act rights.
Raniya Khan
All Responded
2023-0059Deceased 15 Feb 2023 Berkshire
Royal Berkshire NHS Foundation Trust
Concerns summary The hospital failed to implement critical safety undertakings related to placenta retention and staff training, despite previous commitments, raising serious concerns about continued risks.
Minaal Salam
All Responded
2023-0145 13 Feb 2023 Stoke on Trent and North Staffordshire
Stoke on Trent City Council
Concerns summary Inadequate traffic management measures around the school pose an ongoing risk of future deaths, necessitating immediate investigation and improvement.
Maxine Davison, Lee Martyn, Sophie Martyn, Stephen Washington and Kate Shepherd
All Responded
2023-0085Deceased 8 Feb 2023 Plymouth, Torbay and South Devon
Home Office National Police Chiefs’ Council College of Policing
Concerns summary Concerns were raised regarding the risks associated with the legal availability, lethality, ease of use, and rapid fire capabilities of certain items, and their role in crime.
Allah Ismail
All Responded
2022-0411Deceased 22 Dec 2022 Manchester City
British Thoracic Society Healthcare Quality Improvement Partners…
Concerns summary Concerns highlight the need for a national audit of emergency oxygen delivery, updated guidelines for trauma patients and air travel with respiratory conditions, and better use of audit tools by NHS Trusts.
Fatima Abukar
All Responded
2022-0400 14 Dec 2022 East London
Metropolitan Police Service Major retailers of e-scooters Mayor of London +1 more
Concerns summary Reduced enforcement against illegal e-scooter use correlates with increased fatalities, while legal riders aren't required to wear helmets. Inadequate or absent warnings from manufacturers about unlawful use exacerbate safety risks.
Melsadie Parris
All Responded
2022-0390 2 Dec 2022 Buckinghamshire
Buckingham Council Children’s Services
Concerns summary Social work failed to conduct renewed home visits or liaise with mental health teams regarding a carer's admitted psychosis, relying on old assessments and missing critical information about the carer's deteriorating mental state.
Bonnie Webster
All Responded
2022-0378 25 Nov 2022 Norfolk
Queen Elizabeth Hospital
Concerns summary Parents were inadequately informed of the baby's serious condition, antibiotics were significantly delayed, and staff used an inefficient, non-emergency method to alert the paediatric team.
Quinn Parker
All Responded
2022-0287 21 Nov 2022 Nottinghamshire and Nottingham
Nottingham University Hospital NHS Trust
Concerns summary Repeated instances of placentas being interfered with or disposed of prematurely in early neonatal deaths hinder paediatric post-mortem examinations, limiting coronial findings, learning, and parental information.
Awaab Ishak
All Responded
2022-0365 16 Nov 2022 Manchester North
Department of Health and Social Care Communities & Local Government Ministry of Housing
Concerns summary The provided text refers to a Housing Ombudsman report but does not detail specific coroner's concerns.
Molly Russell
All Responded
2022-0315 13 Oct 2022 North London
Department for Culture, Media and Sport Twitter International Company Snap Inc +2 more
Concerns summary Internet platforms lack age verification, age-specific content control, and parental monitoring features, exposing children to harmful material through algorithms and unrestricted access.
Charlotte Warkcup
All Responded
2022-0301 29 Sep 2022 Sunderland
Department of Health and Social Care
Concerns summary Concerns exist regarding the safety of standalone midwife-led birthing centres, the lack of midwife recruitment for continuity of care, and insufficient detection of small gestational age babies.