Child Death

Concerns 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.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns summary Paramedics lacked training in administering buccal midazolam and failed to effectively oxygenate or suction a fitting child, despite clear recommendations from a serious incident report.

Concerns summary A combination of poor communication regarding high-risk pregnancy, lack of clear national guidance for CTG monitoring, and inadequate support and escalation policies for student midwives contributed to critical care gaps.

Concerns summary Govia Thameslink Railway lacked mandatory staff training for vulnerable persons, used inappropriate protocols for welfare concerns, and failed to adequately log actions or share critical information with other agencies.

Concerns summary Urgent review needed for safety measures at non-tidal waters, including warning signs, throw ropes, and buoys, with consideration for applying similar approaches to those used for tidal waters.

Concerns summary NICE Guidance NG121 lacks a clear definition for "large-for-gestational-age" babies, leading to inconsistent interpretation and application of delivery mode guidance. This creates uncertainty in crucial obstetric care decisions.

Concerns summary Persistent delays in mental health assessments and access to psychological therapy are driven by ongoing staff recruitment and retention issues, hindering the Trust's ability to manage increased demand for complex cases.

Concerns summary The absence of dedicated in-patient mental health provision for young people aged 14-25, and the immediate application of adult services at 18, poses risks by not acknowledging developmental needs.

Concerns summary Prison staff were unaware of relevant policies, and there was a critical lack of communication among officers regarding a prisoner's unwell status and need for healthcare, leading to missed checks and handovers.

Concerns summary Safety signs prohibiting swimming were obscured by vegetation and were old, making them less noticeable and explicit about the dangers of the water.

Concerns summary There's been an concerning increase in severe nutritional anaemia and related deaths in children, potentially due to reduced health consultations, limited social contact, and widening socio-economic inequalities exacerbated by the pandemic.