Child Death

Concerns summary The absence of a properly managed and funded national register for Tracheo-Oesophageal Fistula (TOF) cases likely hinders improved outcomes and survival rates.

Concerns summary The Emergency Department's DVT risk assessment failed to consider lower limb immobility from plastic boots, risking patients not receiving crucial anti-clotting medication and developing fatal pulmonary embolisms.

Concerns summary Police officers have limited access to qualified mental health advice and clinical records when responding to mental health crises, as urgent support teams are not readily available and a promised service is unimplemented.

Concerns summary A lack of national standardisation means blood gas analysers in neonatal resuscitation settings often fail to analyse haemoglobin levels, hindering critical decision-making and risking preventable infant deaths.

Concerns summary Policies for high-risk pregnancies were not followed, leading to a failure to consider elective Caesarean Section. There's inadequate training and assessment for junior and locum doctors on identifying serious risk factors.

Concerns summary Midwives attending home births had limited experience, highlighting a lack of specific regulatory requirements for training or ongoing exposure to home birth practice. This raises concerns about maintaining competency in all areas of midwifery practice.

Concerns summary Exceptions to patient confidentiality in mental health cases should be considered when informing third parties could provide crucial non-medical support.

Concerns 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.

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

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

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.

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

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 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 Children's Social Care disengages during mental health admissions, leading to a lack of social worker input in discharge planning and continuity of care, which increases patient risk upon leaving the facility.

Concerns summary CTG monitoring equipment obscured vital graphic data, and key medical staff lacked up-to-date mandated annual CTG training, highlighting systemic failures in equipment design and training compliance.