Child Death

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 There's a lack of national guidance for urgent tonsillectomy referrals in children, especially regarding choking hazards. Delays in care occurred due to staff leave, poor communication between trusts, and inadequate incident investigation systems across company sites.

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 An old, unserviced cot with improperly placed padded boards led to entrapment. Inadequate overnight supervision and the Children's Trust's lack of transparency, scene preservation, and proper investigation exacerbated the issues.

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 Concerns include a midwife being dissuaded from a necessary procedure, leading to delivery delays, inadequate fetal monitoring, and a lack of pre-labour birthing option discussions. "Normal birth" language on checklists is also concerning.

Concerns summary There is a critical lack of specific guidelines for the optimal management of fatal fetal infection, leaving clinicians without assistance in situations like circulatory collapse at birth.

Concerns summary There is no system for monitoring high-risk babies on postnatal wards, leading to insufficient observations and delayed detection of collapse in infants requiring assisted delivery or resuscitation.

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 The resuscitation area was separate from the operating theatre, hampering communication. Critical blood supplies were also located too far away for time-sensitive emergency situations.

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 Inadequate safety measures on a popular bridge and surrounding area fail to deter dangerous activities by teenagers, creating a risk of future tragedies.

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 face dangerously long waiting lists (over a year) for psychological therapy and specialist services like the Gender Identity Clinic, leaving a critical gap in support between urgent and non-urgent mental health interventions.

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 An OFSTED inspection of a children's home was deficient, failing to consider relevant safeguarding information and misinterpreting evidence. Lack of guidance for publishing reports in "exceptional circumstances" led to arbitrary decisions.

Concerns summary Inconsistent terminology for meconium, incomplete medical records, lack of centralised CTG monitoring policy, and a trust policy for "fresh eyes" review that deviates from national guidance are concerns.

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.