Aarav Chopra

Executive Office 
Birmingham Children’s Hospital 
Steelhouse Lane 
Birmingham 
B4 6NH 
Tel: 0121 333 9999 
www.bch.nhs.uk 

By Email Only  
HM Senior Coroner  

5 March 2025 

Dear Ms Hunt 

Aarav Chopra – Regulation 28 : Report to Prevent Future Deaths   

I write in response to your Regulation 28 Report issued to Birmingham Women’s and Children’s NHS 
Foundation Trust on 13 January 2025, following the inquest into the tragic death of Aarav Chopra. 

We would like to express our sincere condolences to the family of Aarav, who have lost a very special 
child. 

I have consulted a number of colleagues in order to respond to your matters of concern below;  

Prophylactic  antibiotics  for  severely  immunocompromised  patients:  The  inquest  heard 
evidence  that  patients  like  Aarav  who  are  immunocompromised  require  additional  prophylactic 
antibiotics for procedures. This is not covered in the current NICE guidelines. Your concern is that 
there is currently no guidance for the use of prophylactic antibiotics in severely immunocompromised 
patients.  
The Hepatology Team are in the process of reviewing the Trust’s Liver Biopsy Guidance and are 
seeking the expert view of Microbiology colleagues to determine any evidence which suggests that 
immunocompromised patients need prophylactic antibiotics at a different time.  

The Trust will respond to expert advice, literature and national guidance on this issue, noting that 
NICE and BNF guidance in context of certain types of surgery states that IV antibiotics should be 
given up to half an hour prior to any procedure even in immunosuppressed individuals. Currently, 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
  
 
 
 
 
 
 
  
 
 
 
 there is no guidance to suggest prophylactic antibiotics should be giving any earlier than is current 
practice.   

Experience and competence of trainees: The inquest heard evidence that there was confusion 
around the experience and level of the trainee involved. He was thought to be an ST6 when he was 
an  ST4.  Your  concern  is  that  there  is  no  mechanism  to  evidence  trainees  experience  and 
competence when they travel to various different hospital trusts as part of their training.  

The resident doctors and fellows have a nominated clinical and/or educational supervisor who has 
an overview of the competence and support required. This information is then shared with the wider 
team through the local faculty meetings.  

We will ensure that this process is strengthened further: 

1.  We  will  ensure  that  there  is  a  formal  record  of  all  trainees  and  fellows  attending  the 

department at any given point in time. 

2.  We will ensure that the information on competence and support will be shared in the local 

faculty group meetings. 

3.  We will ensure that if the trainer is not the named Educational or Clinical Supervisor for the 
resident doctor, then there is a discussion between them to understand fully the competence 
and support required before any procedures or treatment. 

4.  The Chief Medical Officer has communicated with the consultant body in the recent Senior 

Medical and Dental Staff Committee meeting and has followed this up with an email. 

5.  The  Director  of  Medical  Education  will  monitor  this  through  the  Postgraduate  Education 

Governance Structure. 

Consent forms: The parents of Aarav were unaware that a trainee would be doing the liver biopsy. 
Your concern is that there is currently no way to obtain consent when a trainee will be doing the 
procedure.  

GMC consent guidance states that patients and families should be given the right not to be involved 
where teaching, training or research is taking place. Therefore, families should be advised at the 
time of the procedure if a clinician in training may be performing the procedure.  BWC will reinforce 
this  GMC  guidance  to  its  consultant  body  in  order  to  ensure  the  correct  conversations  are  had 
between  colleagues  and  importantly  with  our  families.  This  information  was  shared  in  the  recent 
Senior Medical and Dental Staff Committee meeting and has been followed up with an email to the 
consultant body. 

Individual patient risk factors: Aarav had a complex medical background and several risk factors 
for any procedure. Your concern is that there is currently no mechanism to identify individual patient’s 
risk factors so that all clinicians involved in their care are aware.  

The  importance  of  effective  communication  between  colleagues  will  be  reiterated  across  the 
workforce. In addition to this, the roll out of the Electronic Patient Record (EPR), which is due to go 
live in May 2025 will provide the ability to see at a glance individual patient risk factors.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Learning from deaths: The initial M&M meeting after Aarav's death was described as inadequate. 
Your concern is that there was no immediate learning from this tragedy and further consideration is 
needed  to  ensure  a  safe  and  effective  mechanism  to  properly  learn  from  deaths  at  the  earliest 
opportunity.  

The Trust’s entire M&M process is currently under review. Terms of reference are being developed, 
and support has been requested from the lead at GOSH to assist with the reviews. Meetings with 
the  Clinical  Service  and  Governance  Leads  are  in  place  over  the  coming  weeks  with  4  main 
specialities  at  the  Trust’s  Children's  site  to  review  the  current  practice  and  identify  areas  for 

development. We expect this work to be complete by May 2025. 

A weekly PSIRF Decision Team meeting was set up on 29 April 2024 and is chaired either by the 
Chief Medical Officer or Chief Nursing and Midwifery Officer. In attendance at these meetings are 
appropriate  representatives  from  all  Divisions  within  the  Trust,  who  present  specific  incident 
categories  and deaths  where there  might  be  questions  raised  about  the  care  provided,  identified 
through incident reporting structures and complaints.  

Appropriate  learning  methodology  within the  PSIRF framework  is  agreed  at this meeting  with  the  
oversight of the Chief Medical Officer or Chief Nursing and Midwifery Officer. This provides additional 
assurance of learning with respect to the learning from deaths. We recognise that in Aarav’s case 

these review processes did not immediately capture the relevant learning which in part was owing 
to the transition to PSIRF methodology. As the organisation has adapted to PSIRF, the recognition 
of events requiring this method of investigation has strengthened.  

In addition, governance practice within the Interventional Radiology Department is under review and 
will be amended to ensure that learning is achieved at the earliest opportunity.  

Electronic patient records: You heard evidence that the lack of electronic medical records meant 
clinicians found it difficult to see all of the patient’s medication details. Your concern is that critical 
information can be missed if clinicians do not have access to all the clinical records when planning 
treatment.  

The Trust has procured an EPR which is due to go live in May 2025. It is anticipated that this will 
make all pertinent information available to staff at a glance.  

In addition to the above concerns noted in your Regulation 28 Report to Prevent Future Deaths, I 
would  like  to  address  the  issue  concerning  Aarav’s  antiplatelet  medication,  in  line  with  your 
conclusion that “His death was contributed to by poor planning before the procedure when there was 
no consideration of stopping antiplatelet medication…” 

The Liver Biopsy Protocol has been rewritten to include stopping antiplatelet medication prior to any 
surgical intervention.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Finally, I would like to reinforce the 12 action points from the internal investigation. I have detailed 
these below and indicated the progress of each recommendation. 

Recommendation 1 (LP1)  - When preadmission become aware that antiplatelet medications are 
being continued prior to a liver biopsy, there should be dissemination of this information as early as 
possible  to  both  the  operator  and  anaesthetist  via  the  usual  email  process,  and  positive 
acknowledgement of this fact should be sought. Continuation of antiplatelet medication up to surgery 
should  be  the  exception  rather  than  the  rule,  but  the  final  decision  should  sit  with  the  operator. 
Complete 

Recommendation 2 (LP2) - The threshold for the level of concerns to be discussed at the Sign Out 
should be lowered. Consideration should be given to rewording the Sign Out question for recovery, 
or adding a supplementary question to read ‘Did anything outside the usual course of this procedure 
occur’. Complete 

Recommendation  3  (LP3)  -  The  frequency  of  observations  post-liver  biopsy  should  be 
standardised. In progress 

Recommendation  4  (LP3/4)  -  More  comprehensive  standard  instructions  for  Recovery  after 
intercostal  approaches  to  liver  biopsies  (and  other  procedures carrying  the  same  risk)  should  be 
developed.  This  should  include  the  risks  of  occult  (hidden)  bleeding  into  the  chest  and  focussed 
monitoring of the patient to recognise signs of early haemorrhagic shock. In progress 

Recommendation 5 (LP4) - Enhance training should be provided for recovery staff to recognise the 
difference between emergence delirium and more serious reasons for agitation (as an addition to 
current training, plus simulation practice), together with guidance on seeking further opinion where 
there is any uncertainty. (Currently, recovery staff are PILS (Paediatric Intermediate Life Support) 
trained, however this does not cover surgical complications, so consideration needs to be given to a 
hybrid course covering such issues as recognising occult surgical haemorrhage). First part to lower 
threshold for concern complete, second part – hybrid training in progress 

Recommendation 6 (LP5) - Develop and introduce a process to identify patients with a higher post-
operative risk who would benefit from specific recovery review. Consider how to allow opportunities 
for post-operative Consultant Anaesthetic review within the Consultant Anaesthetic work pattern. It 
may  be  that  the  ‘admin’  Consultant  Anaesthetist  could  perform  this  review  if  the  designated 
anaesthetist was still busy in theatre. In progress 

Recommendation 7 (LP6) - Reinstate a wider process of ward nurses reviewing patients in recovery 
with parents, with joint calculation of current PEWS score between recovery and ward nurses. This 
will improve more timely identification of patients in need of immediate medical attention and possible 
return to theatre.  Complete 

Recommendation  8  (LP7)  -  Implementation of a Trust-wide  process  or mechanism  by which an 
emergency MDT can be convened where the appropriate senior specialists can discuss the most 
appropriate  course  of  patient  management.  As  a  standard  this  should  involve  the  primary  team 
caring for a patient and any anaesthetic and surgical staff involved in any recent procedure. Such 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 an  MDT  could  also  involve  other  senior  staff  with  relevant  expertise  as  required.  This  new 
process/mechanism  will  need  to  be  accompanied  by  wider  education  and  expectations  of 
communication in situations such as this. In progress 

Recommendation  9  (LP8)  -  Disseminate  learning  about  management  of  haemothorax  from  this 
case in trauma scenario training and by distribution of a 1-page summary of the incident and the 
learning points identified. In progress 

Recommendation 10 (LP9) - Highlight the importance of detailed documentation of emergencies 
and  ongoing  resuscitation  events  across  the  Trust.  Such  documentation  should  include  what 
happened  and  the  rationale  for  management  decisions  made.  This  should  be  built  into  scenario 
training across the Trust and in the ED and PICU Medical Education programme. In progress 

Recommendation 11 (LP9) - The Trust is introducing an electronic patient record system from next 
year which will mean that routine printing of data following emergency events on PICU will not be 
necessary.  However,  in  the  interim  PICU  should  consider  which  other  non-arrest  resuscitation 
scenarios might benefit from post-event printing of data for the purpose of review and learning. In 
progress 

Recommendation 12 (LP10) - PICU, Anaesthetic and Surgical consultants should work side by side 
in managing cases of significant surgical haemorrhage admitted to PICU (in a similar way to how 
they already do in cases of difficult airway management), to effectively harness the complementary 
skill sets of the specialties involved. In progress 

I  hope  this  letter  assures  you  that  the  concerns  you  raised  have  been  reviewed  thoroughly  and 
changes actioned where possible. I would like to reassure you that we have taken the learning from 
Aarav’s death very seriously.  

Yours sincerely 

Chief Medical Officer 

On behalf of  

Chief Executive Officer

Minister of State for Health (Secondary Care) 

39 Victoria Street 
London 
SW1H 0EU 

24th March 2025 

Our ref: 

HM Coroner Louise Hunt  
The Birmingham and Solihull Coroner’s Court,  
Steelhouse Lane, Birmingham,  
B4 6BJ 

By email: 

Dear Ms Hunt,  

Thank you for the Regulation 28 report of 13 January 2025 sent to the Department of Health 
and Social Care regarding the death of Aarav Pal Chopra.  

Firstly, I would like to say how saddened I was to read of the circumstances of Aarav’s death, 
and I offer my sincere condolences to their family and loved ones. The circumstances your 
report describes are concerning and I am grateful to you for bringing these matters to my 
attention. Please accept my sincere apologies for the delay in responding to this matter and 
thank you for the additional time provided to the  Department to provide a response to the 
concerns raised in the report. 

The report raises six matters of concerns, related to: 

1.  Prophylactic antibiotics for severely immunocompromised patients 
2.  Experience and competence of trainees 
3.  Consent forms 
4.  Individual patient risk factors 
5.  Learning from deaths 
6.  Electronic patient records 

In preparing this response, my officials have made enquiries with NHS England, the Care 
Quality  Commission  (CQC),  and  the  National  Institute  of  Health  and  Care  Excellence 
(NICE), to ensure we adequately address your concerns. I will do my best to address each 
of the concerns sequentially. 

1.  Prophylactic antibiotics for severely immunocompromised patients: 

We have confirmed that there is no specific guidance from NICE relating to the management 
of immunosuppression or immunocompromise specifically. Although immunocompromise is 
discussed, as appropriate, in disease-specific guidance, NICE does not have such guidance 
on the care of children or young people following liver transplant. There is also no specific 
guidance from NICE relating to a liver biopsy in a person following a liver transplant. 

 
 
 
 
 
 
 
 
 
 
  
 
 
 
  
  
 
 
 
  
 NICE feel that this is a highly specialised area that is likely to have limited evidence, and 
therefore,  the  subject  would  be  best  covered  by  a  consensus-based  clinical  practice 
guideline developed by a specialist medical society.  

Such  guidance  has  been  produced  as  a  position  paper  by  the  European  Society  for 
Paediatric  Gastroenterology,  Hepatology,  and  Nutrition.  (Dezsofi  et  al.  Liver  Biopsy  in 
Children:  Position  Paper  of  the  ESPGHAN Hepatology  Committee.  JPGN  2015;60:  408–
420).  

Guidance relating, primarily, to adult practice has also been produced by the British Society 
of Gastroenterology, the Royal College of Radiologists, and the Royal College of Pathology 
(Neuberger  J,  Patel  J,  Caldwell  H,  et  al.  Guidelines  on  the  use  of  liver  biopsy  in  clinical 
practice from the British Society of Gastroenterology, the Royal College of Radiologists and 
the Royal College of Pathology. Gut 2020; 69:1382-1403).  

Although  these  guidelines  recommend  that  antibiotic  prophylaxis  should  not  be  used 
routinely, they do not cover the specific situation outlined in your report. Similarly, the use of 
prophylactic  antibiotics  in  immunocompromised  children  following  a  liver  transplant  is  a 
highly specialised area that would be best covered by a consensus-based clinical practice 
guideline developed by a specialist medical society. 

2.  Experience and competence of trainees 

The National Education and Training Team, via NHS England have explained that where a 
resident  doctor  is  on  a  training  placement  in  a  Trust,  information  relating  to  their  level  of 
experience and competence is available via TIS (the Trainee Information System) and in 
their portfolio, which their Clinical and Educational Supervisors have access to.  

The Trust has advised the team that the doctor involved in this case was on a fellowship.  I 
am aware that Birmingham Women's and Children's NHS Foundation Trust (BWCH), which 
is responding to you directly,  should be able to provide details of how this was arranged, 
and  what  information  was  shared  in  advance.  The  doctor  had  been  working  in  the 
department  for 3  months,  and  the  team  understand  from  the  Trust  that  no  concerns  had 
been raised about their performance, prior to this event. 

3.  Consent forms 

The National Team Children and Young People, via NHS England, have confirmed that the 
current consent forms specifically state that the consent does  not specify which individual 
will undertake a procedure.  

They  have  suggested  that,  if  consent  for  training  is  required,  this  will  potentially  greatly 
impact the ability to train the next generation of clinicians. Furthermore, the evidence is that 
outcomes  are  better  when  procedures  are  performed  by  trainees  under  supervision,  as 
compared to procedures performed by consultants. Clearly there are confounding factors, 
but this demonstrates that the current system largely works. 

4.  Individual patient risk factors 

 
 
 
 
 
 
  
 
  
 
 
  
 
 
 
 
 
 The National Team Children and Young People have suggested that all Electronic Patient 
Records (EPRs) should have summary problem lists that detail all diagnoses for that patient.  
The  NHS  Federated  Data  Platform  (NHS  FDP)  holds  promise  in  joining  primary  and 
secondary care records to share diagnostic and therapeutic data. Further information about 
NHS FDP can be found at: NHS England » NHS Federated Data Platform 

5.  Learning from deaths 

The Department has approached NHS England to comment on the point raised regarding 
the ‘inadequate’ Mortality & Morbidity (M&M) meeting that was held following Aarav’s death. 
NHS  England  has  confirmed  that  Birmingham  Women's  and  Children's  NHS  Foundation 
Trust will address these concerns in their own response to the report. 

The Care Quality Commission (CQC) has confirmed that they it is aware of this death and 
has reviewed it under its Specific Incident Guidance. As part of this review, the case has 
also been progressed to the Criminal Cases Assessment Progression Panel (CCAPP) for a 
decision as to whether CQC will begin a criminal investigation in line with the organisation’s 
enforcement policy.  

The CQC has stated that it cannot comment on a live investigation, however, it is considering 
all aspects of this incident including the report’s matters of concern. The CQC was also in 
attendance at the Inquiry and will use any relevant evidence to inform their investigation. 
Further information will be communicated to the family in due course. 

6.  Electronic patient records 

 NHS England has informed the Department that BWCH are implementing EPIC Electronic 
Patient Records (EPR), which should help with the Trust’s progress towards improved data 
integration.  Further  information  regarding  NHS  EPR  system  expansion  can  be  found  at: 
Digitising the frontline - Digitise, connect, transform - NHS Transformation Directorate  As 
discussed in point 4., NHS FDP should enhance information sharing further by integrating 
primary and secondary care patient data. 

I hope this response is helpful. Thank you for bringing these concerns to my attention.   

Yours sincerely,  

MINISTER OF STATE FOR HEALTH