Child Death

Concerns summary The absence of professional guidance and training for midwives performing vaginal pushes during fetal extraction, alongside inconsistent use of fetal pillows, contributed to a fetal head injury.

Concerns summary Despite guidance, young parents are continuing unsafe co-sleeping practices, often involving alcohol or drugs, and are not appreciating or following advice on safe sleeping environments, risking infant deaths.

Concerns summary Failures included inadequate risk assessment for delivery, incorrect forceps use due to insufficient training, excessive force, poor locum staff management, communication breakdowns, and unsuitable resuscitation equipment in maternity.

Concerns summary No specific concerns were detailed in the provided text for this report.

Concerns summary Critical learning issues, including inadequate patient handover procedures for midwives, remained unaddressed a year after the death, with no specific training or effective reflective discussions implemented.

Concerns summary Midwives are potentially deployed to community roles too soon after qualifying, lacking adequate experience, which is a concern for patient safety across the nation.

Concerns summary Concerns exist regarding whether an appropriate operating or instruction manual was obtained for the inflatable trampoline, which exploded and caused a fatality.

Concerns summary There is no speed limit on the road adjacent to the school, failing to slow traffic during critical times when children are arriving and leaving the school.

Concerns summary Insufficient communication of blind cord dangers to new parents, absence of a national safety leaflet, and missed opportunities for healthcare professionals to provide warnings contributed to the risk.

Concerns summary The maternity unit suffered from insufficient capacity for safe care, and consultant guidance inappropriately limited the availability of caesarean sections following failed inductions.

Concerns summary The Scout Association failed to implement or ensure understanding of critical safety policies, including risk assessments and leadership oversight, for an organised trip, directly endangering young people.

Concerns summary Safeguarding referrals were closed without parental contact, and referral information was not shared with other agencies due to data protection concerns. This practice potentially deprives social workers of vital context and undermines child protection.

Concerns summary Failure to refer a patient for a clinical geneticist's opinion, despite repeated parental requests and available services, led to a critical underlying condition remaining undiagnosed, resulting in premature death.

Concerns summary The A34 bypass (Melrose Way Bend) is dangerous due to the lack of a continuous white line, allowing unsafe overtaking on a dark stretch of road.

Concerns summary Critical information sharing failures between hospital departments, absence of pre-operative ECMO assessment and post-operative planning, conflicting extubation advice, and delayed ECMO commencement critically compromised patient care.

Concerns summary Significant delays in accessing specialized services due to heavy caseloads, outdated written care plans despite family requests, and a failure to implement crucial multi-disciplinary emergency response training.

Concerns summary Other public authorities may have unaddressed safety issues similar to Wirral MBC's tree management, necessitating national learning and action from the tragic death.

Concerns summary Serious fractures and head injuries sustained in a road traffic collision were critically overlooked when the deceased attended the hospital.

Concerns summary Local Authorities with high numbers of young people in care lack sufficient resources and qualified staff, further compounded by poor integration between care, mental health, and educational support services.

Concerns summary The CAMHS/GP referral form is inadequate, resulting in insufficient information for risk assessment and delayed care; the Trust should reconsider redesigning the form.

Concerns summary The approximate age of moped riders was not communicated to the police tactical team, omitting a relevant factor for risk assessment and decision-making.

Concerns summary A dysfunctional team exhibited unclear clinical leadership, poor CTG interpretation and communication, inadequate record-keeping, and insufficient staffing, with junior staff unable to challenge decisions.

Concerns summary Systemic failures in allergy management included poor understanding by pupils and staff, unchecked medication, non-standardised action plans, and inadequate awareness of critical EpiPen administration protocols.

Concerns summary School friends were aware of the deceased's increasing suicidal ideation and methods explored online but failed to report it to adults, partly due to fear of device bans.

Concerns summary The inability to trace a doctor who left the UK after treating a patient compromised the investigation and prevented the clinician from learning from issues raised.