Child Death

Concerns summary A lack of national guidance for clinicians on considering and diagnosing Autoimmune Encephalitis creates a risk of missed diagnoses and future deaths.

Concerns summary A lack of regulation, registration, and clear guidance for doulas creates confusion about their role, risks them working outside clinical boundaries, and poses challenges for midwives and patient care.

Concerns summary The absence of a nationally validated sepsis screening tool for Paediatric Emergency Departments and inconsistent application of the trust's own tool across units risk delayed sepsis diagnosis.

Concerns summary Healthcare professionals failed to inquire about the contents of 'bottle-fed' milk and did not use interpreters for a non-English speaking mother, reflecting a lack of professional curiosity and adherence to guidance.

Concerns summary A critical communication breakdown between hospital and GP regarding medication monitoring, combined with repeated failures by GPs to check clinical records, left a child unprotected from fatal infection.

Concerns summary There is an absence of national guidance for the use of propofol for short-term sedation in children and young people in paediatric intensive care units.

Concerns summary Extensive and thick black mould in the property managed by Granddwell Estates poses a significant risk of future deaths.

Concerns summary Pathology protocols for suspected anaphylaxis need revision to ensure appropriate sample collection and retention. Police investigations of unexplained child deaths also lack procedures for seizing and retaining crucial scene evidence.

Concerns summary There are inadequate age restrictions on dangerous aerosol products and unclear warnings about instant death. Social media platforms also fail to take responsibility for harmful content promoting such misuse.

Concerns summary There is a lack of national guidance and relevant training for the increasingly common obstetric emergency of impacted fetal head during caesarean sections.

Concerns summary A significant majority of obstetricians have not received crucial specific training related to this incident, raising concerns about the trust's commitment to learning and patient safety.

Concerns summary The hotel room lacked secondary security for its easily disengaged door locks, and the pool had no physical barrier, allowing unsupervised access by a vulnerable child.

Concerns summary Vulnerable children can access online suicide material, and international service providers’ jurisdictional stance can obstruct coronial investigations, hindering efforts to prevent future deaths.

Concerns summary Paramedics lacked mandatory training and experience in obstetric emergencies, specifically breech deliveries, and national guidelines were not adhered to, leading to delayed intervention during a critical birth.

Concerns summary Dangerous road conditions, including ungritted ice and flowing water, were not addressed despite public reports. The existing reporting systems for road faults were unclear and disparate, leading to a failure to act on these critical safety concerns.

Concerns summary Critical delays in performing a Caesarean section were caused by significant communication failures among staff, inadequate training on recognising abnormal foetal movements, and poor escalation protocols, compounded by consultant oversight.

Concerns summary Long waiting lists for first appointments at Gender Dysphoria clinics pose a significant risk, delaying crucial care for vulnerable individuals.

Concerns summary Significant delays in ambulance dispatch were caused by prolonged handover times at emergency departments, potentially impacting patient care despite not affecting the specific outcome in this case.

Concerns summary Hospital trusts generally lack processes to document external calls from midwives, leading to poor continuity and escalation of care, especially regarding parental concerns, and increasing risk of future deaths.

Concerns summary Significant gaps in shotgun licence regulation, including no requirement to declare multiple properties or movement, and less stringent application criteria compared to firearms, create a risk of future deaths.

Concerns summary Over-administration of analgesia during labour rendered the mother comatose, masking labour progression, and current national guidelines lack explicit detail on safe analgesia levels and supervision.

Concerns summary Inadequate face-to-face weight monitoring, confusion over consultant-to-consultant referrals, and discharge from CAMHS without direct patient contact or engagement exploration were significant concerns. Dietetic assessments were also limited to telephone.

Concerns summary There is a concerning widespread lack of serial paediatric nursing observations, with medical staff failing to identify their absence, leading to an unsafe patient discharge.

Concerns summary Inadequate algorithms for assessing ill newborns/infants, particularly for respiratory problems, and over-reliance on these tools lead to delays in obtaining early clinical assessment.

Concerns summary The Child Sepsis Screening Tool is not fully embedded, meningitis guidelines are not completely implemented, and fragmented record-keeping across systems risks vital clinical information being lost.