Child Death

Concerns 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.

Concerns summary The legal framework concerning Nitrous Oxide needs review due to increasing use by young persons and its association with deaths.

Concerns 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.

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.

Concerns summary Oncology consultants inappropriately lead care for APML patients, where significant bleeding risks require haematologist expertise, exacerbated by a national shortage of specialists.

Concerns summary A critical failure to provide a case manager or key worker for autistic young people, as per NICE guidance, limits access to support services and prevents navigation of care pathways.

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.

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.

Concerns summary Inadequate traffic management measures around the school pose an ongoing risk of future deaths, necessitating immediate investigation and improvement.

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.

Concerns 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.

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.

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.

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.

Concerns 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.

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.

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.

Concerns summary The provided text refers to a Housing Ombudsman report but does not detail specific coroner's concerns.

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.

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.

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 The coroner questioned why charges under the Children and Young Persons Act were not brought against the parents, given the evidence presented.

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 lack of national guidance on feeding expectations for low-risk, formula-fed babies in their first 72 hours risks premature discharge and insufficient information for families on signs of concern.