Child Death
PFD Category
Reports: 443
Areas: 65
Earliest: Jan 2015
Latest: 26 Mar 2026
79% response rate (above 63% average). 38% of classified responses show concrete action taken. Reports fell 2% from 57 (2023) to 56 (2024).
PFD Reports
294 resultsMolly-Ann Sergeant
All Responded
2023-0078Deceased
19 Feb 2023
Essex
Essex Partnership NHS Foundation Trust …
Concerns summary (AI 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.
Action Taken
(AI summary)
Essex County Council has undertaken training and awareness raising with the Children and Families Hub and operational teams regarding referrals to Social Care. They have clarified that every young person in an in-patient unit is a child-in-need and needs to remain open to Social Care, who must be involved in discharge arrangements. There has also been widespread focus and awareness raising in relation to Section 117 and Section 85.
Raniya Khan
All Responded
2023-0059Deceased
15 Feb 2023
Berkshire
Royal Berkshire NHS Foundation Trust
Concerns summary (AI 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.
Action Taken
(AI summary)
The Trust has implemented a process for storing placentas for 48 hours for histological examination, detailed in SOP MATSOP064, and has also strengthened the Policy for feedback of concerns raised about temporary agency staff; the issue of agency staff was raised with the BOB LMNS and Regional Chief Midwife to take forward. The Trust has updated psychotherapy discharge letters to include prompts for discharge planning, requires written communication with the locality MDT team prior to the discharge of patients on Section 117 aftercare plans, and will update CPA review documentation to ensure carers are involved in the review process.
Minaal Salam
All Responded
2023-0145
13 Feb 2023
Stoke on Trent and North Staffordshire
Stoke on Trent City Council
Concerns summary (AI summary)
Inadequate traffic management measures around the school pose an ongoing risk of future deaths, necessitating immediate investigation and improvement.
Action Planned
(AI summary)
Stoke-on-Trent City Council proposes to amend speed cushions into a full carriageway tapered road hump on Waterside Drive. They also plan to introduce school zig zag markings and double yellow lines on Waterside Drive to improve road safety.
Maxine Davison, Lee Martyn, Sophie Martyn, Stephen Washington and Kate Shepherd
All Responded
2023-0085Deceased
8 Feb 2023
Plymouth, Torbay and South Devon
Approved Clubs
self-governing schools
Chief Constables
+5 more
Concerns summary (AI 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.
Disputed
(AI summary)
North Wales Police will review cases over the last 5 years where applications have been refused or licenses revoked, but where subsequent applications or appeals resulted in a grant, aiming to complete this by 2nd October 2023. They highlight existing processes for quality control and previous review work undertaken. Avon and Somerset Police completed a review and found no cases where approval should not have been granted. They are reviewing their training requirements and will be implementing additional mandatory training for all staff, including PiP Level 1 training. Dorset Police will provide additional training to further enhance the quality of FEO investigations through the national Professionalising Investigations Programme at level 1 over the next 18 months. A presentation of the key learning from the incident to a CPD event for all Firearms Licensing Managers will be delivered in May 2023. Merseyside Police firearms enquiry officers have completed the South Yorkshire Police training package and are enrolled on Mowbray Partners online training. They will also review cases within one month where firearms were seized or surrendered but subsequently returned, and applications refused/licenses revoked but later granted, aiming to complete this by 2nd October 2023. South Wales Police is reviewing approximately 1300 records where certificate holders were subject to a suitability review to determine if certificates were seized, surrendered, revoked or refused and subsequently approved. They are also working with Gwent Police to align processes, conduct peer reviews, and arrange an annual peer assessment of firearms licensing approvals. North Yorkshire Police has established a Gold group to oversee their response and commenced a review of records relating to certificates seized, refused, revoked, or surrendered and then subsequently approved over the last 5 years, aiming for completion by October 2nd. They are developing an Action Plan to manage the response and record decisions. Lancashire Constabulary has commenced a review of all certificates refused, revoked, seized or surrendered and then subsequently approved over the past 5 years, against the March 2023 Home Office Statutory Guidance, expected to be completed by the end of October 2023. They have also introduced process and scrutiny changes, including a dedicated Chief Inspector responsible for Firearms Licensing and training for staff. Greater Manchester Police will review between 70-80 cases at Senior Officer Panel, for the five-year period, where certificates have been seized, refused, revoked or surrendered and then subsequently approved and guns returned. The Firearms Licensing Manager and Detective Sergeant will attend a two-day continuous professional development (CPD) event delivered by Chief Constable Tedds at the College of Policing on the 18th and 19th May 2023. The College of Policing is developing significantly revised and updated Authorised Professional Practice (APP) on firearms licensing. This will underpin the development of a national training course for staff involved in firearms licensing. Gloucestershire Constabulary will conduct a review of firearms licensing decisions, as per the letter from the NPCC lead, with a target completion date of 2 October 2023. Surrey Police will review firearms and shotgun licensing prioritizing cases where firearms have been seized or surrendered and then returned; it will review most recent decisions first and applications that have been refused or licences revoked but where subsequent applications/appeals resulted in a grant. An additional resource has been seconded into the department to expedite this review and provide a full report by 2nd October 2023. Norfolk Constabulary will commission external training for Firearms Licensing Unit staff starting in May 2023. They will also conduct a review of certificates seized, refused, revoked, or surrendered and then subsequently approved, prioritizing cases not already subject to renewal, with a dip-sample approach to other cases. Essex Police is reviewing decisions to return firearms licenses over a five-year period, prioritizing cases where firearms were seized or surrendered and then returned. They have implemented local training for firearms licensing staff, including a lesson plan developed collaboratively with Kent Police, and external auditors will review the team's compliance. Bedfordshire Cambridgeshire and Hertfordshire Police have instructed a review of firearms seized and returned, certificate holders refused or revoked then successfully reapplied, and holders subject to police intelligence reports over the last five years. New role-specific training is being undertaken by all Firearms Explosives Licencing Unit staff, and an external training package has been purchased. West Mercia Police will review firearms licensing decisions related to returns, refusals, revocations, and surrenders over the past five years, aiming to complete the review by the end of October. A designated team, including a firearms instructor and tactical advisor, will conduct the review. Sussex Police's Firearms and Explosives Licencing Unit believes its process for the return of a certificate is suitably stringent and is catered for within a force policy; the team is working with the national NPCC lead and the College of Policing in developing a national curriculum and learning outcomes for Firearms Enquiry Officers, and will be active participants at the two day CPD event hosted by the College of Policing in May 2023. Kent Police will review 134 firearms licensing cases where certificates were returned after seizure/surrender, or granted after refusal/revocation, assessing them against the current Home Office Statutory Guidance. Local firearms licensing training, including refresher courses and mentoring, is provided, with plans to develop a lesson plan with Essex Police by the end of August 2023. Northamptonshire Police will prioritise reviewing cases where firearms have been seized/surrendered and then returned, and cases where applications were refused/licenses revoked but later granted, completing this by 2nd October 2023. They have secured temporary resources and engaged external companies to audit the unit. Devon and Cornwall Police invested £3 million into the force's Firearms and Explosives Licensing Unit (FELU). In 2023, training is planned, including integrating firearms licensing into practical scenarios for Personal Safety Training and presenting key learning from the incident at CPD events. City of London Police acknowledge the findings and learnings from the Keyham Inquest and will review their SOP to ensure procedures for Application / Annual Renewal / Return meet or exceed common national standards, including robust checks across medical, crime recording and Risk Assessment. Risk assessment training and CPD training for all licensing team will be implemented on an annual cycle. The Lord Chief Justice acknowledges the concerns but states that the report does not substantiate the suggestion that judges are not giving appeals the necessary careful and detailed consideration, are applying the incorrect legal test, or are failing to have regard to the statutory guidance. Nottinghamshire Police has identified a dedicated resource to review firearms licensing cases where firearms were seized/surrendered and later returned, or where licenses were refused/revoked and later granted. A sample of cases from a 2021 review will be independently re-reviewed, and all reviews will be completed by 2 October 2023. Durham Constabulary details their history of firearms licensing reform following a 2013 report and states that they are satisfied that their review of decisions to return firearms to licence holders after seizure or surrender was appropriate and subjected to the appropriate level of scrutiny and oversight. Staffordshire Police and West Midlands Police (collaborated service) provided tables that outline certificates seized and returned, revoked, and refused. They have a series of scheduled quality assurance programmes in relation to internal and external audits over decision making. The Metropolitan Police expresses condolences and describes existing processes for reviewing firearms licensing decisions, including reviews conducted in August 2021, and states they are contributing to national discussions on firearms licensing training. They explain the process used to identify cases for review following the Home Secretary's request. Leicestershire Police will review cases from April 2023 for the past 5 years where certificates were seized, refused, revoked or surrendered and then subsequently approved, prioritizing cases where firearms were seized or surrendered. The review will be conducted by individuals independent from the original decision makers and findings will be reported to the strategic lead for Firearms Licensing. Staffordshire Police (and West Midlands Police, as part of a collaborated service) detail existing training for staff, including the National Triage Firearms Classification Course and Police National Decision Model training. They also refer to the review of certificates seized, refused, revoked or surrendered and subsequently approved. The Home Office is allocating £500,000 to the College of Policing to develop accredited training for firearms licensing staff. They will consult on mandating this training and are working to address health information sharing, in consultation with medical bodies. Thames Valley Police will review seized and returned guns over a 5-year period, grants that have been revoked/refused/surrendered, and applications refused/revoked but subsequently granted via appeal. The aim is to complete these stages by 2 October 2023. Devon and Cornwall Police completed a review of 611 license holders identified as meeting the criteria of having certificates seized, refused, revoked or surrendered and then subsequently approved between May 2018 and December 2019. Eleven of these cases identified internal processes that did not meet expected standards, but no ongoing risks were identified. Warwickshire Police states that they have already responded to the Home Secretary's request in 2021 regarding license applications that were refused or revoked but subsequently granted. The force will direct a review of firearms and shotgun licensing, prioritizing cases where firearms were seized or surrendered but then returned. Suffolk Constabulary will review cases relating to certificates issued between April 2019 and August 2020. For other periods, they will dip-sample cases, with a wider review if concerns are identified, and highlight prior review work undertaken in Autumn 2021. Derbyshire Police has implemented IT system improvements for recording and sharing information, ensuring automatic notifications to the firearms licensing team for incidents involving license holders. They are developing a digital learning package for frontline officers and are exploring an independent scrutiny panel. Dyfed Powys Police will undertake a further review of decision files where firearms have been seized following any incident and subsequently returned to the holder. They welcome and support the recommendation of the Coroner to formalise a training programme to encompass all Firearms roles and responsibilities.
Fatima Abukar
All Responded
2022-0400
14 Dec 2022
East London
Major retailers of e-scooters
Mayor of London
Metropolitan Police Service
+1 more
Concerns summary (AI 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.
Noted
(AI summary)
Amazon includes a warning on e-scooter product pages stating they are prohibited on public roads in the UK, makes the warning prominent with bold font and a link to government guidance, sends communications to selling partners to remove references to public road use, and publishes education for selling partners on local legal restrictions. Escooterclinic attributes the incident to reckless user behavior, not the vehicle itself. They advise legalizing scooters with regulations and compulsory protective gear/insurance, citing confusion caused by legal rental scooters. Selfridges ensures there are clearly visible messages in stores and on their website stating that e-scooters may not be lawfully ridden on public highways. The legal team has issued reminders to stores and digital teams regarding this matter and are exploring system-based solutions for safety advisory requirements. Halfords advises potential buyers about the legal restrictions on e-scooter use at all stages of the sales process, both in-store and online, using prominent signage, legal statements on price tickets and warranties, and colleague training. They are also pushing for regulation in any Transport Bill. The MPS has published information on the MPS public website regarding the illegality of e-scooters, provides a flowchart to officers on how to deal with illegal e-scooter use and sends letters to e-scooter retailers asking them to display prominent signs about the legality of e-scooters. The MPS disputes that there is a correlation between legal enforcement of e-scooters and number of deaths and states that policy regarding head protection for licensed e-scooters was a decision made by the Department for Transport and Transport for London. Harrods is preparing notices for display in the Technology department and on their website, clarifying the illegality of e-scooter use on public roads. They also recommend helmets to customers and are implementing age verification checks. TfL highlights safety measures in the e-scooter rental trials, including speed limits, always-on lights, and minimum wheel size. They also promote safety guidance and have worked with the MPS to raise awareness of the law regarding private e-scooters. Onboards displays helmets with scooters, offers helmet discounts, encourages helmet use in-store, and features helmeted riders in online media. They display a sign about the illegality of private e-scooter use, include a disclaimer on invoices and website footer, and do not sell scooters to under-18s. The DVSA has been conducting market surveillance and has sent warning letters to retailers selling e-scooters without proper warnings about illegal use on public land. The government encourages helmet use for e-scooter trials and will consult on helmet wearing for future regulation. Evolve Skateboards is reviewing safety and legal compliance globally, including the UK, with expected rollout by June 2023. They are also a founding member of a PMD safety group advising the Land Transport Safety and Regulation Bureau in Queensland, Australia.
Melsadie Parris
All Responded
2022-0390
2 Dec 2022
Buckinghamshire
Buckingham Council Children’s Services
Concerns summary (AI 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.
Noted
(AI summary)
Buckinghamshire Children's Social Care acknowledges the coroner's concerns regarding a comment made by a carer. They note the coroner's finding that the child was not at risk at the time and state that without new evidence, they would have no legal right to insist on a further visit.
Bonnie Webster
All Responded
2022-0378
25 Nov 2022
Norfolk
Queen Elizabeth Hospital
Concerns summary (AI 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.
Action Planned
(AI summary)
The Queen Elizabeth Hospital King's Lynn plans to implement mandatory training for clinical staff on communication skills, documentation and escalation, and will establish a group to improve processes in the maternity unit.
Quinn Parker
All Responded
2022-0287
21 Nov 2022
Nottinghamshire and Nottingham
Nottingham University Hospital NHS Trust
Concerns summary (AI 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.
Action Planned
(AI summary)
The clinical team has been reminded to highlight potential placental pathology on request forms. The Director of Midwifery has reminded midwives to examine placentas prior to sending them to pathology. A new proforma has been introduced for BMS to complete at the time of placenta preparation. The Trust will extend the Pathology stop period across the board for all placentas and have discussions with the Coroner's office where a death occurs within 96 hours. This approach is considered more achievable than trying to predict which of the 975 NICU admissions each year will die. The Trust will develop a standard procedure to ensure the medical examiner team informs the pathology laboratory of any neonatal death within 48 hours of birth at the earliest opportunity. The Pathology Department will review examination processes after further information is gained regarding placental examination.
Awaab Ishak
All Responded
2022-0365
16 Nov 2022
Manchester North
Department of Health and Social Care
Ministry of Housing, Communities & Loca…
Concerns summary (AI summary)
The provided text refers to a Housing Ombudsman report but does not detail specific coroner's concerns.
Noted
(AI summary)
The Secretary of State calls on social housing providers to treat damp and mould seriously, meet the Decent Homes Standard, and self-refer to the Regulator of Social Housing if in breach of standards. They also highlight the upcoming Social Housing Regulation Bill to hold landlords accountable. The Secretary of State requests local authorities prioritize improving housing conditions for private and social tenants, focusing on damp and mould. They request information on the number of properties with damp and mould and how enforcement of housing standards is being prioritized. The Secretary of State asks legal representatives to direct social housing tenants with concerns about housing to the Social Housing Ombudsman, highlighting recent changes making it easier to access the Ombudsman. The government outlines actions taken to address damp and mould in social housing, including issuing guidance to landlords, suspending funding to Rochdale Boroughwide Housing, and awarding funding to areas with poor privately rented homes. They also highlight the Social Housing Regulation Bill to hold landlords accountable.
Charlotte Warkcup
All Responded
2022-0301
29 Sep 2022
Sunderland
Department of Health and Social Care
Concerns summary (AI 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.
Action Planned
(AI summary)
Version 3 of the Saving Babies’ Lives Care Bundle is being developed for publication in 2023, aiming to introduce a more nuanced risk assessment and clarify guidance for staff.
Harper Denton
All Responded
2022-0288
15 Sep 2022
Bedfordshire and Luton
Metropolitan Police, College of Policin…
Concerns summary (AI summary)
Police forces failed to adopt guidance for managing violent offenders and lacked proactive information sharing to protect children. Additionally, a national register for child cruelty offenders is missing, and health visitor safeguarding assessments are not mandatory.
Action Planned
(AI summary)
The College of Policing will update APP (Authorised Professional Practice) within three months to clarify that disclosure of information about a person who poses a risk of harm can be made to parents and/or carers of children. The MPS is reviewing its MAPPA processes, including scoping the feasibility of introducing a Potentially Dangerous Person (PDP) process as outlined by the College of Policing’s APP Guidance; the outcome of this review is anticipated within six months. The Home Office is considering options for better management of domestic abuse offenders, including a domestic abuse 'register', and is working to improve information and data sharing between agencies for safeguarding children, with a report due before Parliament in Summer 2023. The Department is updating resources for health visitors and school nurses, emphasizing assessments of family relationships and chronology of events for children with additional needs, due to be published shortly. They have also agreed to a cross-government programme of work focusing on strengthening whole family approaches and improving evidence.
Asher Sinclair
All Responded
2022-0272
4 Sep 2022
West London
Clinical Commissioning Group
NHS England
Concerns summary (AI summary)
A highly vulnerable child was not provided prescribed 2:1 care, their complex package lacked proper review or quality checks, and critical parental concerns were ignored, compounded by inadequate staff training.
Noted
(AI summary)
NHS North West London has implemented a single children’s continuing care team with registered nurses and experienced managers providing a consistent service. A parental agreement has been developed which sets out expectations and responsibilities in regard to parental responsibility. NHS England highlights the resources provided by The National Tracheostomy Safety Project (NTSP) and notes the NWL's response addressing training, supervision and care packages. They also mention that all reports received are discussed by the Regulation 28 Working Group to share key learnings.
Robyn Skilton
All Responded
2022-0247
7 Aug 2022
West Sussex
Department of Health and Social Care
Concerns summary (AI summary)
Significant underfunding and under-resourcing of CAMHS caused extensive waiting times for child psychiatrist assessments, preventing timely diagnosis and treatment. Exploding referral rates without proportionate resource increases have made the service unsustainable, endangering young people.
Noted
(AI summary)
The response acknowledges concerns about access to child and adolescent mental health services (CAMHS) in West Sussex. It outlines national initiatives to increase funding for and access to mental health services, including potential waiting time standards, and mentions a public call for evidence.
Adele Massoudi
All Responded
2022-0185
20 Jun 2022
Berkshire
Royal Berkshire NHS Foundation Trust
Concerns summary (AI summary)
A midwife delayed calling an ambulance despite meconium in a home birth, prioritizing other tasks, raising concerns about insufficient urgency in training. Additionally, the placenta was not retained, hindering vital examination for learning.
Action Taken
(AI summary)
Royal Berkshire NHS Foundation Trust commissioned an external midwifery report and is developing an action plan to address recommendations for future training provision. A new SOP provides guidance on placenta histology, storage, and retention, and all Band 7 midwives and Unit Coordinators will be trained on the new SOP.
Esma Guzel
All Responded
2022-0233
1 Jun 2022
Hull and East Riding of Yorkshire
NHS Digital
NHS Pathways
Royal College of General Practitioners
+1 more
Concerns summary (AI summary)
The 111 algorithm failed to prompt urgent paediatric referral for a critically ill child, inadequately considering parental concern, prior GP review, and timing of advice, leading to delayed optimal care.
Noted
(AI summary)
The RCPCH acknowledges the concerns and will share the report with its Quality in Clinical Practice committee for further discussion to identify opportunities to prevent future deaths, and will continue to collaborate with the RCGP on safe and effective pathways of care for children and young people, ensuring the child health workforce is represented in national discussions on children’s urgent and emergency healthcare, and patient safety. NHS Digital reports that the 111 algorithm was modified and provides detail on the governance structure overseeing NHS Pathways, including independent oversight, consistency with NICE guidelines, and a process for reporting incidents and requesting changes. The RCGP acknowledges the concerns, outlines educational material for GPs in training, and welcomes changes to the 111 out-of-hours algorithm. They support investment in primary care infrastructure to improve data sharing, but note that dissemination of a rare case report is not currently considered necessary.
Cassian Curry
All Responded
2022-0120
25 Apr 2022
South Yorkshire (West District)
Sheffield Teaching Hospitals NHS Founda…
Concerns summary (AI summary)
Parents were not informed of a critical consultant plan for a central line review. Concerns also include a lack of consideration for national form suitability and how regional support is accessed for highly vulnerable babies.
Action Taken
(AI summary)
The Trust is working with the South Yorkshire Neonatal Operational Development Network to deliver a network-wide action plan for increased family involvement in neonatal care, and the updated umbilical line insertion checklist now includes a specific entry requirement for informing parents if the catheter is in a suboptimal position.
Oliver Lindsay
All Responded
2022-0103
6 Apr 2022
Manchester South
Department of Health and Social Care
Concerns summary (AI summary)
Delays in urgent fetal growth scans due to capacity issues, coupled with a lack of widespread understanding of fetal growth restriction risks, compromise timely intervention and parental awareness.
Action Taken
(AI summary)
NHSEI published a Core Competency Framework to address variation in maternity and neonatal training and competency assessment, including training on the Saving Babies Lives Care Bundle Version 2, which includes monitoring fetal growth restriction.
Samuel Alban-Stanley
All Responded
2022-0082
12 Mar 2022
North East Kent
Department of Health and Social Care
NHS Kent and Medway Clinical Commission…
Concerns summary (AI summary)
Inadequate support and psychosocial interventions were provided for a child with Prader Willi syndrome and high-risk behaviours. Poor communication between agencies also prevented coordinated care.
Action Planned
(AI summary)
North East London Foundation Trust is working with the Kent and Medway ICS and the local authority to learn lessons from the report, and has put training in place for all relevant staff on the signs and impacts of the relevant condition, and introduced reviews for high complexity cases. Training on Prader-Willi syndrome has been provided to CYPMHS staff at NELFT, and joint posts have been created across the Local Authority and Primary Care to identify children with additional needs early. Kent has also mobilised the National NHS England Designated Key Worker Early Adopter programme and continues to develop programmes for early intervention and support. The Department for Education is working with the Children’s Commissioner’s Office and the Information Commissioner’s Office (ICO) to identify ways to better improve data sharing in child safeguarding cases. They have also committed to publishing an ambitious implementation strategy later this year.
Edward Akroyd
All Responded
2022-0069
4 Mar 2022
West Yorkshire Western
Calderdale and Huddersfield Foundation …
Concerns summary (AI summary)
No specific concerns identified within the provided text, which details a critical condition and subsequent death following an expedited delivery due to abnormal CTG tracing.
Noted
(AI summary)
The Trust outlines actions taken in response to concerns, including updating guidelines for maternal blood pressure checks and CTG interpretation, changing processes for escalating concerns, and ensuring timely review of blood test results. They also describe actions related to training and competence assessment of midwives. The Trust requests redaction of specific concerns and responses from publication, arguing they could identify individual clinical staff and contain personal information.
Martha Mills
All Responded
2022-0063
28 Feb 2022
Inner North London
King’s College Hospital NHS Foundation …
Concerns summary (AI summary)
Delayed referral to paediatric intensivists and a suboptimal paper-based early warning score system contributed to a preventable death. A critical program to improve inter-departmental collaboration has stalled.
Action Taken
(AI summary)
King's College Hospital outlines actions taken and planned following a serious incident investigation, including establishing regular meetings between departments, developing new care pathways, improving access to specialist services, and providing additional training. They also detail how ongoing actions will be monitored.
Adrian Balog
All Responded
2022-0056
23 Feb 2022
Manchester City
Department for Education
Concerns summary (AI summary)
National safeguarding guidance for children omits "obesity" as a sign of neglect, contrasting with malnourishment, which risks failing to identify and protect obese children at risk.
Noted
(AI summary)
The Secretary of State acknowledges concerns about including 'obesity' as an indicator of abuse and neglect in safeguarding guidance, highlighting existing guidance on safeguarding children's welfare and health. They note existing initiatives to improve access to services for children living with overweight or obesity and refer to the Independent Review of Children’s Social Care, stating that the concerns will be considered in the context of the review's recommendations.
Jake Cahill
All Responded
2022-0032
1 Feb 2022
Cornwall & the Isles of Scilly
Youth Justice Board for England and Wal…
Concerns summary (AI summary)
Vulnerable young people complete self-assessment forms without professional discussion about sensitive issues, a gap compounded by inadequate guidance from the Youth Justice Board.
Action Taken
(AI summary)
The Youth Justice Board has updated national guidance to support practitioners in using self-assessment tools appropriately when engaging with children. The updated guidance covers topics such as bail, custody, family and health.
Oskar Nash
All Responded
2022-0031
31 Jan 2022
Surrey
Department for Education
Department of Health and Social Care
National Child Safeguarding Review Panel
+3 more
Concerns summary (AI summary)
Child mental health services lack mandatory Autism training for triage staff, risking inadequate understanding and inappropriate closure of referrals. Routine referrals are automatically deemed low risk, despite potential for significant harm.
Action Planned
(AI summary)
The council made Autism awareness training mandatory for all staff working directly with children and young people, to be completed by 31 March 2022. It noted the Coroner's concern regarding post-death reviews, stating that SCC follows national guidance and took appropriate steps by way of a Thematic Review which was accepted by the National Panel. The CCG details actions taken including a Surrey CDR team meeting, incorporating thematic review learning into Surrey Children Services academy training, establishing a multi-agency task and finish group and a children and young person subgroup of the Surrey Suicide Prevention Partnership. Oskar's death will be presented at the next suicide themed CDOP meeting and learning shared nationally via NCMD. The Department for Education is conducting reviews of special educational needs and disability and of the children’s social care system, which will lead to significant reform of the support available for the most vulnerable of children and young people. The Child Safeguarding Practice Review Panel are developing a framework for undertaking rapid reviews, developing a quality assurance framework and publishing anonymised examples of good quality rapid reviews as exemplars of good practice.
Coco Bradford
All Responded
2022-0012
18 Jan 2022
Cornwall and the Isles of Scilly
National Institute for Health & Care Ex…
Concerns summary (AI summary)
Outdated IV fluid guidelines for children in shock posed a risk of fluid overload, and there was no clear guidance on balancing antibiotic use for sepsis against the risk of HUS in bacterial gastroenteritis.
Action Planned
(AI summary)
NICE acknowledges the guideline on gastroenteritis in under 5s [CG84] does not align with the UK Resuscitation Council’s 2021 guideline on paediatric advanced life support, and has forwarded the report to their guideline surveillance team who will review the UK Resuscitation Council’s 2021 guideline and consider if CG84 and other related NICE guidance need to be updated.
Luke Wilden
All Responded
2022-0015
16 Jan 2022
Bedfordshire and Luton
East London NHS Foundation Trust
NHS England
Concerns summary (AI summary)
Inadequate transition arrangements within mental health services for young adults with high-functioning autism resulted in a lack of continued treatment and appropriate social care. This service gap may exist nationally.
Action Planned
(AI summary)
NHS England is working with ELFT to strengthen knowledge and understanding of transitions issues in each other’s areas and a shared transition protocol or protocols that link together. They are committed to improving the availability of inpatient mental health support and alternatives to admission for Children and Young People. The Trust has reinforced transition protocols, reviewed the serious incident report into Mr Wilden’s death and the Trust’s transition policy and protocols with relevant staff members. An administrator pulls a list of all existing service users on a monthly basis to address the transitions policy.