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
443 results
Chester Mossop
All Responded
2023-0127 20 Apr 2023 Cumbria
Office of Product Safety and Standards
Concerns summary (AI summary) The report expresses concern that bath seats may give parents a false sense of security and that parents/carers may not be provided with advice about the safe use of bath seats.
Action Planned (AI summary) NHS England will update its ‘Washing and bathing your baby’ website page with guidance on the use of bath seats, highlighting that they are not recommended by RoSPA or the Child Accident Prevention Trust, and is undertaking a communications push to highlight the importance of never leaving babies of any age unsupervised while in the bath; OHID will be raising the case with their networks as a safety alert. OPSS will assess the safety and compliance of similar baby bath seat models and work with the Baby Products Association to reinforce requirements for safe use instructions and clear safety warnings; they will also engage with the NHS to explore incorporating safety messages related to baby bath seats.
Alexandra Briess
Partially Responded
2023-0117 6 Apr 2023 Berkshire
Department of Health and Social Care Medicines and Healthcare Products Regul… NHS England +1 more
Concerns summary (AI summary) A critical lack of national systems for capturing and reporting anaphylaxis cases, especially fatal and near-fatal ones, along with no named accountability for allergy services, impedes understanding and prevention.
Noted (AI summary) NHS England acknowledges concerns around anaphylaxis and highlights discussions with stakeholders to improve data collection, understanding, and research. They reference the Immunology and Allergy Clinical Reference Group, specialised allergy service specifications, and initiatives by BSACI and the Royal College of Physicians. The Department of Health and Social Care acknowledges the concerns about national leadership on allergy services and capturing anaphylaxis cases. They mention that NHS England is responsible for clinical policy and strategy and highlight the establishment of an Expert Advisory Group for Allergy and the UK Fatal Anaphylaxis Registry.
REDACTED
Historic (No Identified Response)
2023-0115 3 Apr 2023 Blackpool & Fylde
Children’s Commissioner for England Department for Education Department of Health and Social Care
Concerns summary (AI summary) Unacceptably long waiting times for young people's assessments due to finite resources placed children at risk, suggesting that earlier diagnosis and professional support could prevent deaths.
Louis Rogers
Partially Responded
2023-0108Deceased 28 Mar 2023 Surrey
Joint Royal Colleges Ambulance Liaison … National Institute for Health and Care … NHS England +3 more
Concerns summary (AI summary) Inadequate management and investigation of febrile seizures, including insufficient parental information, deficiencies in paramedic guidelines, and GP assessment, contributed to missed opportunities for timely intervention and specialist referral.
Noted (AI summary) NHS England refers to NICE guidance and Clinical Knowledge Summaries for managing febrile seizures, and notes work underway to review training on child death review processes and support for families. They are also considering the Surrey Heartlands Integrated Care System’s Child Death Review and discussing reports to prevent future deaths. The Royal College of Emergency Medicine acknowledges the complex nature of managing febrile seizures and expresses willingness to collaborate with other organizations to develop further evidence-based guidance. The AACE has made medical directors and lead paramedics aware of the circumstances and asked them to review JRCALC guidance and local pathways. They also reminded ambulance trusts of the NASMeD guidance on conveying children by operational ambulance clinicians. NICE believes existing guidance (CG137, replaced by NG217) and Clinical Knowledge Summaries sufficiently cover assessment of febrile seizures. They are participating in system-level discussions with NHS England and the Royal College of Paediatrics and Child Health regarding SUDIC research and action.
Kayleigh Burns
Historic (No Identified Response)
2023-0106Deceased 27 Mar 2023 Warwickshire
Ministry for Justice
Concerns summary (AI summary) The report raises the issue of whether the present legal framework concerning Nitrous Oxide should be reviewed, in light of this death, having regard to the seemingly increasing use of Nitrous Oxide particularly by young persons.
Benjamin Nelson-Roux
Partially Responded
2023-0103Deceased 23 Mar 2023 North Yorkshire and York
Department of Health and Social Care Harrogate Borough council North Yorkshire County Council
Concerns summary (AI summary) The system failed to find suitable accommodation for a homeless 16-year-old by limiting searches to county boundaries and lacking residential substance misuse treatment facilities for minors.
Action Planned (AI summary) North Yorkshire Council is updating its Joint Working Protocol with housing providers to include out-of-area accommodation searches and clarify responsibilities when placing young people outside the county. They anticipate completion within six months. The Department of Health and Social Care acknowledges the limited availability of residential substance misuse treatment for young people, emphasizing community-based interventions. They highlight increased funding for local authorities to improve community drug and alcohol services for children and young people, leading to a 27% increase in treatment numbers since March 2022.
Kyron Hibbert
All Responded
2023-0077Deceased 27 Feb 2023 Bedfordshire and Luton
Forest of Marston Vale Trust
Concerns summary (AI summary) The Trust failed to address known drowning risks at a lake, with inadequate supervision, missing water depth warnings, and inaccessible life-saving equipment.
Action Planned (AI summary) While not accepting that equipment was too far away, the Trust will install additional unlocked throw lines closer to the high water mark by 1st June 2023. They will also issue safety messages to local schools during warm weather.
Katie Wilkins
All Responded
2023-0041Deceased 26 Feb 2023 Liverpool and Wirral
Department of Health and Social Care
Concerns summary (AI summary) Oncology consultants inappropriately lead care for APML patients, where significant bleeding risks require haematologist expertise, exacerbated by a national shortage of specialists.
Action Taken (AI summary) The Department of Health and Social Care notes that Alder Hey Children's NHS Trust undertook a Root Cause Analysis and implemented improvements, including reviewing handover arrangements. The government is also working to ensure adequate medical school places and increase doctor retention.
Molly-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.
Stefan Kluibenschadl
Historic (No Identified Response)
2023-0068Deceased 19 Feb 2023 North East Kent
NHS Kent and Medway Clinical Commission…
Concerns summary (AI summary) The report identifies a lack of case managers or key workers for young people diagnosed with autism, contrary to NICE guidance, which may prevent them and their families navigating available services.
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) 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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.
Toby Barwick
Historic (No Identified Response)
2023-0030Deceased 27 Jan 2023 East London
Department of Health & Social Care University College London Hospitals NHS…
Concerns summary (AI summary) Parents of a low birth weight infant were not provided essential SIDS prevention advice and documentation upon discharge, and the hospital failed to demonstrate that the underlying omission was corrected.
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.
Arthur Trott
Historic (No Identified Response)
2022-0387 29 Nov 2022 West Sussex
Joint Royal Colleges Ambulance Liaison …
Concerns summary (AI summary) Inadequate JRCALC guidance on footling breech presentation led to an inappropriate home delivery attempt and delayed hospital transfer. There is also a critical shortage of consultant midwives providing obstetric support across ambulance services.
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 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 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 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.
Molly Russell
Partially Responded
2022-0315 13 Oct 2022 North London
Baker & McKenzie LLP Department for Digital, Culture, Media … Meta Platforms +5 more
Concerns summary (AI summary) Internet platforms lack age verification, age-specific content control, and parental monitoring features, exposing children to harmful material through algorithms and unrestricted access.
Action Planned (AI summary) Twitter acknowledges the concerns and highlights existing safety features, including user controls to manage content, block accounts, and a parental controls guide developed with Internet Matters. Meta highlights existing tools and policies, including content moderation, reporting options, and parental supervision features. They also mention partnerships with experts and engagement with the UK Online Safety Bill. Snap highlights existing safety measures and resources, including reporting tools, partnerships with mental health organizations, and extra protections for under 18s. They mention a Global Safety Advisory Board that includes UK members. The government plans to strengthen online protections for children via the Online Safety Bill, including requiring platforms to publish risk assessments and naming the Children's Commissioner as a statutory consultee for Ofcom. Pinterest commits to limiting the distribution of depressive content to teens, updating its self-harm policy for stricter enforcement, partnering with a third-party content checking service, improving moderation processes, and expanding resources for parents. These actions are planned for implementation by the end of 2023.
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.
Dainton Gittos
Historic (No Identified Response)
2022-0269 31 Aug 2022 Lincolnshire
Constable of Lincolnshire
Concerns summary (AI summary) The coroner questioned why charges under the Children and Young Persons Act were not brought against the parents, given the evidence presented.