Maya Zab

From Maggie Throup MP 
Parliamentary Under Secretary of State for Vaccines and Public Health 

39 Victoria Street 
London 
SW1H 0EU 

Mr Ian Pears 
HM Assistant Coroner, West Yorkshire (Western) 
City Courts 
The Tyrls 
Bradford, BD1 1LA 

13 December 2021

Dear Mr Pears, 

Thank you for your letter of 16 September 2021 to the Department of Health and Social 
Care about the death of Maya Zab.  I am replying as Minister with portfolio responsibility 
for Child Health and I am grateful for the additional time in which to do so.  

I would first like to say how deeply saddened I was to read the circumstances of baby 
Maya’s death.  To lose a child, and at such a young age, must be devastating and I offer 
my heartfelt condolences to her parents and all who loved and knew Maya.    

In preparing this response, my officials brought your concerns to the attention of the 
Regional Director of Public Health in the North East and Yorkshire, and made enquiries 
with NHS England and NHS Improvement (NHSEI), to which you also issued your report.  

NHSEI advises that data relating to diagnoses of iron deficiency anaemia1 does not show 
any significant increase nationally or regionally.  The numbers regionally, by month, are 
generally quite low and can vary considerably month by month.  However, the overall trend 
shows no significant increase.  I hope this information is helpful.  

Of course, it is distressing that some infants suffer serious harm or even death as a result 
of poor nutrition, and I wish to assure you that we are determined to do all we can to 
prevent these deaths.   

1 Secondary User Service (SUS) data, NHS England national clinical data repository. ICD diagnosis codes 
D508 ‘Other iron deficiency anaemias’, and D509 ‘Iron deficiency anaemia, unspecified, primary and 
secondary care.  

 
 
 We recognise the need to offer universal support to families with infants.  The Healthy 
Child Programme: 0-5 years2 aims to offer every family five health and wellbeing reviews 
(from prenatal to infant) that are universal in reach and personalised in response.  These 
should be face-to-face, delivered by a health visitor, or by another qualified professional 
under their supervision.  There may also be more intensive home visiting support for 
vulnerable families.  Where necessary, health visitors offer additional support to families 
and refer them onto other services. 

In the course of their reviews, health visitors use clinical judgement alongside 
formal screening and assessment tools to identify health and development needs, 
safeguarding concerns and provide personalised advice and guidance to families. 

Universal services remain essential for keeping children safe and for primary prevention, 
identifying needs and areas for support before a situation becomes an issue that needs to 
be addressed.  Health visiting services are targeting resources to those where support is 
most needed.  The spend per head in the most deprived areas is higher compared to the 
least deprived areas where spend per head is lower. 

We recognise the impact the pandemic has had on the delivery of health visiting services.  
With the onset of COVID-19, some public health nurses were redeployed, but were 
repatriated by the end of July 2020.  

In response to winter planning in 2020, Public Health England and NHSEI Chief Nurses, 
together with the Local Government Association, wrote to Directors of Nursing to advise 
that professionals supporting children and families, such as health visitors, school nurses, 
designated safeguarding officers and nurses supporting children with special educational 
needs should not be redeployed to other services and should be supported to provide 
services through pregnancy, early years and to the most vulnerable families3. 

An updated health visiting and school nurse service delivery model, together with 
commissioning guidance, was published in March 20214. 

Even before the start of the pandemic, local authorities had a mixed model of delivery for 
health visitors.  Specialist community public health nurses should use their clinical 
judgement to identify whether virtual, other digital or blended approaches can be used to 
support the needs of a child or family.  During the pandemic, community health services 
have continued to provide support, with greater use of digital and remote technologies and 
prioritisation of higher needs families. 

We are working with academics from Keele University to identify currently available 
evidence on the impact of digital technologies on public health service delivery to children, 
young people and families.  The specific objective of this work is to identify the quality of 
digitally delivered services in relation to quality of engagement and development of 

2 Policy paper overview: Healthy Child Programme: Pregnancy and the First 5 Years of Life - GOV.UK 
(www.gov.uk) 

3 https://www.local.gov.uk/joint-letter-winter-planning-support-children-and-families-7-october-2020  
4 https://www.gov.uk/government/publications/commissioning-of-public-health-services-for-children/health-
visiting-and-school-nursing-service-delivery-model  

 
 
 
 
 
  
 
 
 
 
 
 therapeutic relationships.  This evidence will be made available to local service 
commissioners, their providers and professionals to inform future service design. 

The Government does not have any plans to introduce policies to specifically target 
nutritional anaemia in children.  However, the Government’s efforts to promote a healthy 
balanced diet for children contribute to this goal by encouraging the intake of food rich in 
nutrients essential to preventing anaemia, such as iron.  

Government advice on a healthy, balanced diet is encapsulated in the UK’s national food 
model, the Eatwell Guide5.  The Eatwell Guide is a visual representation of the types and 
proportions of foods needed for a healthy balanced diet.  The Eatwell Guide includes a 
variety of iron rich foods, such as, fortified cereals, red meat, vegetables, nuts, eggs and 
fish. 

In addition, the Healthy Start Scheme supports hundreds of thousands of pregnant 
women and families on lower incomes to make healthier food choices.  Pregnant women 
and families with children aged under four and over receive one voucher per week, worth 
£4.25, and families with children under one receive two vouchers, worth £8.50 in total, 
every week.  These vouchers can be used to buy, or be put towards the cost 
of, fresh, frozen or tinned fruit and vegetables, fresh, dried and tinned pulses, plain cow’s 
milk and infant formula.  Healthy Start beneficiaries also receive free vitamins.  

The NHS Business Service Authority’s work to digitise the Healthy Start scheme is well 
underway and this will make it easier for families to apply for, receive and use Healthy 
Start benefits.  Digitisation will replace the current paper application form, with an online 
application and replace the paper vouchers with a prepaid card. 

I hope this information is helpful and demonstrates the range of action being taken to raise 
awareness and target action to prevent the risk of future tragic deaths such as that of 
Maya Zab.   

Thank you for bringing these concerns to my attention.  

Yours Sincerely, 

MAGGIE THROUP 

5 The Eatwell Guide - NHS (www.nhs.uk)

Ian Pears, HM Assistant Coroner 
West Yorkshire  
City Courts,  
The Tyrls,  
Bradford  
BD1 1LA 

National Medical Director & 
Interim Chief Executive, NHSI 
Skipton House 
80 London Road 
London 
SE1 6LH 

26th November 2021 

Dear Mr Ian Pears 

Re: Regulation 28 Report to Prevent Future Deaths – Maya Zab, 6th August 
2020 

Thank you for your Regulation 28 Report dated 16 September 2021 the death of 
Maya Zab on 6 August 2020. Firstly, I would like to express my deep condolences to 
Maya’s family.  

I note that the inquest last year concluded that Maya’s death was a result of: 
1a Multiorgan Failure 
1b Chronic Severe Microcytic Hypochromic Anaemia with Severe Iron Deficiency 

Further following the conclusion of the inquest, I note that you have raised the 
following concerns within your Regulation 28 Report for NHS England to consider: 

During the course of the evidence it became clear that in the Yorkshire & 
Humber region there has been an increased incidence of severe nutritional 
anaemia in 2020 in a paediatric setting, resulting in 2 deaths, Maya’s death 
being one of the two. The witness had not seen any deaths previously in her 
career. 

The witness had consulted 9 colleagues over the data. They surmise that a 
number of factors arising indirectly from the pandemic may explain the 
findings: 

1. The “stay at home” message resulted in less 1 to 1 consultations, so health

professionals were not able to spot the signs of anaemia.

2. Limitation of social contact meant other professionals and friends and family

were not able to report concerns about a child’s health.

NHS England and NHS Improvement 

 
 3.  Widening of socio-economic inequalities (including unemployment and 
reduced household earning capacities) means that certain members of 
society are not able to purchase a balanced, good quality nutrition for their 
children. 

Whilst contact with the NHS was reduced during the pandemic, there was also a 
clear narrative that the NHS remains open for patients who need care, and this 
remains the message.  NHSEI is working hard to restore services across the 
country.  

We recognise the impact the pandemic has had on the delivery of health visiting 
services.  With the onset of COVID-19, some public health nurses were redeployed, 
however I can confirm that they were all repatriated by the end of July 2020. 

In response to Winter Planning in 2020, Public Health England and NHSEI Chief 
Nurses, together with the Local Government Association, wrote to Directors of 
Nursing across the country to advise that professionals supporting children and 
families, such as health visitors, school nurses, designated safeguarding officers and 
nurses supporting children with special educational needs, should not be redeployed 
to other services and should be supported to provide services through pregnancy, 
early years and to the most vulnerable families. (Joint letter on Winter Planning: 
Support to Children and Families, 7 October 2020 | Local Government Association.) 

Further an updated health visiting and school nurse service delivery model, together 
with commissioning guidance, was also published in March 2021. (Health visiting 
and school nursing service delivery model - GOV.UK (www.gov.uk).) 

Even before the start of the pandemic, I can confirm that local authorities had a 
mixed model of delivery for health visitors.  Specialist community public health 
nurses should use their clinical judgement to identify whether virtual, other digital or 
blended approaches can be used to support the needs of a child or family.  During 
the pandemic, community health services have continued to provide such support, 
albeit with greater use of digital and remote technologies and the prioritisation of 
higher needs families. 

I am able to confirm that DHSC are currently working with academics from Keele 
University to identify available evidence on the impact of digital technologies on 
public health service delivery to children, young people and families. The specific 
objective of this work is to identify the quality of digitally delivered services in relation 
to quality of engagement and development of therapeutic relationships.  This 
evidence will then be made available to local service commissioners, their providers 
and professionals to inform future service design. 

In terms of your concern regarding the widening of socio-economic inequalities, I can 
confirm that NHSEI are working to integrate care across the country with a particular 
focus on addressing inequalities and supporting children, young people and their 
families who may be vulnerable.  

It was agreed that working with the NHS Business Services Authority (NHS BSA) to 
raise the profile and uptake of the Healthy Start programme would benefit both 

 
 
  
  
  
 
 
 
 pregnant mothers and children to provide children with the best start in life 
regardless of circumstances. 

The Healthy start programme helps  parents with children under the age of 4 and 
pregnant women to buy healthy food and milk. The scheme is in the process of 
transferring from paper vouchers to a digital cards, this will support quicker 
application decisions, allow use of the cards anywhere that accepts Mastercard®, 
automatic top up every 4 weeks, allows partial use of allowance (not previously 
available) and is discreet payment option.  

National data sets do not show any national or regional increases in 
malnutrition. The data used was the secondary user service (SUS) data in the NHS 
England national clinical data repository (NCDR), the equivalent data is available on 
the NHS Digital website, where the data is available as a provisional dataset.   

The SUS malnutrition data using ICD diagnosis codes D508 - Other iron deficiency 
anaemias and D509 - Iron deficiency anaemia, unspecified, in any position (primary 
or secondary) does not show any significant increase nationally or regionally. The 
numbers regionally by month are generally quite low and can vary considerably 
month to month however the overall trend shows no significant increase. 

Thank you for bringing these important patient safety issues to my attention and 
please do not hesitate to contact me should you need any further information. 

Yours sincerely, 

National Medical Director & 
Interim Chief Executive, NHSI