Child Death

Noted (AI summary) Medway Maritime Hospital updated its paediatric guidelines (version 6.8) and uploaded them to QPulse in March 2021. The updated guidelines include factors that doctors need to be aware of in clinical presentation, assessment requirements, and monitoring levels. RCPCH has shared the report with the British Paediatric Neurology Association (BPNA) to raise awareness on recognising and managing Hypokalaemia. They will discuss hosting a webinar to increase awareness of this case and to promote current NICE guidance, and will also be meeting with the Neonatal and Paediatric Pharmacist Group to discuss case-based discussion podcasts. The Department of Health and Social Care acknowledges the concerns, notes actions taken by the Medway NHS Foundation Trust and the RCPCH, and references NICE guidance on intravenous fluid therapy in children. It states the NICE guidance is not mandatory and does not override clinical judgement.

Noted (AI summary) The RCPCH acknowledges the concern about Vitamin D supplementation advice in the Red Book, but states that the current edition already contains relevant guidance. They suggest the issue is one of professional practice rather than a deficiency in College standards. NICE states that their guideline PH56 already recommends including questions about vitamin D supplements in the Red Book, and that the RCPCH is best placed to amend the book's content. NICE will liaise with NHSX and NHS Digital to improve alignment between digital content and NICE guidance. They will consider the coroner's report when the guideline is next reviewed. The Department acknowledges concerns about vitamin D supplementation and highlights existing guidance and the Healthy Start scheme. They refer to an ongoing review into improving health outcomes in babies and young children but do not commit to any specific changes to vitamin D policy.

Noted (AI summary) The Trust will ensure that when obtaining an independent third-party or independent clinical opinion in the future, this is done on a more formal basis with clear terms of reference. A sticker with independent palpation of maternal pulse will be in front of CTG machine by the end of February 2021, and actions are planned to ensure a robust process is in place regarding CTG monitoring interpretation and escalation. The DHSC expresses condolences and highlights existing NICE guidelines and national initiatives related to maternity care and fetal monitoring. It also notes that HSIB has been made aware of the report.

Noted (AI summary) The DHSC outlines existing guidance, training and resources related to safe sleeping for infants, including collaboration with Public Health England and the Lullaby Trust. It also notes advice given to local authorities during the pandemic regarding prioritizing health visitor services and awaits a report from the Early Years Health Advisor.

Noted (AI summary) Greater Manchester Police has conducted a review into the triage process of district safeguarding teams, is developing a triage training course including guidance on information sharing, and has recruited a Domestic Abuse Coordinator to ensure a consistent approach to MARACs across the force. Trafford Council states it has already made significant improvements to policies and procedures since 2018 and believes the coroner's concerns are directed to central government. Greater Manchester Health and Social Care Partnership will present learning from the Serious Case Review to the Greater Manchester Quality Board and share it with commissioners of services for consideration. The CPS acknowledges differences in the definitions of a serial domestic abuser and explains the role of the prosecutor in relation to reasonable lines of enquiry. The Dept. of Health and Social Care notes the concerns raised, mentions a Serious Case Review and review of its action plan, and states that local authorities are responsible for commissioning health visitor services based on local needs. The Home Office describes national actions to manage perpetrators of abuse including College of Policing guidance, a review of the Domestic Violence Disclosure Scheme (Clare's Law), and the introduction of new Domestic Abuse Protection Orders (DAPOs) with associated training for police.

Noted (AI summary) NHS England highlights the existing advice available on the NHS Choices website and the role of Health Visitors in delivering the Healthy Child Programme. PHE aims to reduce preventable accidents as part of the national priority on Best Start in Life (2020-2025) through the modernisation of the Healthy Child Programme. The RCN has reviewed and strengthened its guidance about the potential risks of strangulation and suffocation on its clinical webpages for Health Visitors, Midwives, School Nurses, Children’s Nurses, Neonatal Nurses and General Practice Nurses. This matter has also been brought to the attention of members through Forums and social media platforms.

Noted (AI summary) The document provides general guidance on safer sleep practices for newborns, focusing on recommendations for reducing the risk of sudden infant death syndrome (SIDS).