Esme Atkinson

Parliamentary Under-Secretary of State for    
Patient Safety, Women’s Health and Mental Health  

39 Victoria Street   
London   
SW1H 0EU   

HM Coroner Alison Mutch  
Coroner’s Court,  
1 Mount Tabor Street,  
Stockport, 
SK1 3AG  

15 August 2025  

Dear Ms Mutch,   

Thank you for the Regulation 28 report of 6 June sent to the Secretary of State for Health 
and Social Care regarding the tragic death of Esme Vera Louise Atkinson.   

Firstly, I was saddened to read of the circumstances of Esme’s death, and I offer my sincere 
condolences to Esme’s family and loved ones. The circumstances your report describes are 
concerning  and  I  am  grateful  to  you  for  bringing  them  to  my  attention.  In  preparing  this 
response,  my  officials  have  made  enquiries  with  NHS  England  to  ensure  we  adequately 
address  your  concerns.  We  recognise  that  several  opportunities  for  the  identification  of 
Esme’s heart defect were missed and that there needs to be improvement in the areas set 
out below. Our responses to your specific concerns are as follows:  

The Inquest heard evidence that health visitors, midwives and GPs play a key role in the 
early identification of a heart defect, such as Esme’s, at an early stage. They heard that such 
a  defect  will  rarely  be  apparent  at  the  72-hour  check,  but  symptoms  will  manifest 
subsequently. You raised concerns that training for community midwives, health visitors and 
GPs  on  early  identification  of  heart  defects  needs  to  be  improved,  with  good  quality 
information  sharing  essential.  You  mentioned  that  this  should  include  concerns  around 
feeding  and  weight  loss.  You  also  flagged  that  it  was  important  that  health  professionals 
involved in the care of a baby understood that the mother being diabetic increased the risk 
of  a  defect  significantly  and  should  increase  the  care  taken  in  relation  to  presenting 
symptoms.  

We agree that health visitors, midwives and GPs play a key role in identifying heart defects 
at an early stage, and that sharing of good quality information is essential in facilitating this. 
We also agree with the importance of healthcare professionals understanding what factors 
could increase the risk of heart defects in babies. We recognise that this could have been 
improved in Esme’s case, as she was seen by GPs on three occasions and the community 
midwifery services.   

  
    
  
  
  
  
 
 
  
  
 To support the early identification of conditions, NHS England has put in place nationally- 
mandated, annual multi-professional training which includes training modules on diabetes in 
pregnancy, care during labour, the immediate postnatal period (including a focus on infant 
feeding), and practical simulations to recognise and escalate care for deteriorating mothers 
or babies. There is a compliance benchmark of >90% staff attendance, providing assurance 
that key competencies are being routinely reinforced across the workforce.    

Screening of babies is routinely carried out both antenatally and postnatally through the Fetal 
Anomaly  Screening  Programme  (FASP)  and  the  Newborn  and  Infant  Physical  Screening 
Programme (NIPE). Further information about these programmes, and the training available 
to healthcare professionals to deliver them, is provided below.   

Antenatal Screening   

Antenatal screening is carried out by the FASP to screen for 11 physical conditions, one of 
which is congenital heart disease.  

Screening  through  the  FASP  is  conducted  by  midwives,  who  are  supported  with  learning 
resources and local screening co-ordinators to enable up to date understanding of screening 
and conditions to enable discussions with families that support informed choice.  

Providers  are  responsible  for  assessing  the  competence  of  each  practitioner  before  they 
scan  independently  and  are  responsible  for  making  sure  staff  receive  sufficient  time  to 
complete  minimum  training  requirements.  They  should  ensure  training  is  completed  and 
recorded, and that there should be a system in place to assess ongoing competence.   

Postnatal Screening   

Postnatally, the NIPE recommends the offer of screening to all babies born in England for 
conditions relating to the eyes, heart, hips and testes (if applicable).   

The NIPE newborn screening examination must be completed by a trained practitioner. This 
can be a midwife, neonatal nurse, a qualified doctor, or a health visitor who has successfully 
completed a university-accredited ‘examination of the newborn’ programme of study.   

The  NIPE  handbook,  which  informs  and  supports  best  clinical  practice  for  healthcare 
professionals,  was  updated  in  April  2024.  This  included  an  updated  list  of  risk  factors, 
categorisation  of  congenital  heart  disease,  additional  information  on  undertaking  heart 
examinations  (observation,  palpation  auscultation),  and  enhanced  sections  on  the 
management of babies with screen negative and screen positive results.   

We  recognise  the  importance  of  practitioners  establishing  relevant  information  about  the 
mother’s medical history and the baby’s family history as part of the NIPE, and recognise 
that this would have been particularly important in Esme’s case. Best practice sets out that 
practitioners should ask parents if they have any concerns about their baby’s breathing or 
colour when their baby is at rest or feeding or if their baby is not feeding well. Practitioners 
are also informed about the risk factors for Congenital Heart Disease and encouraged to 
have increased vigilance during the screening examination if the mother has type 1 diabetes.   

Effective information sharing at the point of transfer of care - for example, from secondary to 
primary care, and from midwifery to health visitor care - is also essential.  As set out in NICE 

 guidance, details such as pregnancy history, maternal conditions (e.g. diabetes), and any 
concerns about feeding or growth, should be shared to ensure continuity and safety in care.   

You also flagged that the GP check at 6-8 weeks is a key checking point and that GPs must 
ask the right questions and have a good understanding of how to listen for a heart defect 
such as Esme’s. We agree that the GP check at 6-8 weeks (also known as the newborn 
infant examination) is a key checking point, as it provides the opportunity to conduct a further 
physical examination to assess development and check for any possible conditions relating 
to the eyes, heart, hips and testes (if applicable). We likewise recognise how important this 
is, particularly in Esme’s case, given that some conditions can develop or become apparent 
after the newborn screen described above.   

While the 6–8-week check is not a formally-managed part of the NIPE programme, regional 
commissioners provide scrutiny, as required, to oversee this part of the examination. The 
NIPE  screening  programme  also  produces  best  practice  guidance  and  recommended 
referral timescales in relation to the infant screening examination.  

We  recognise  the  importance  of  ensuring  continued  development  and  training  for 
practitioners conducting the 6-8 week check. NHS England’s Learning Hub provides relevant 
online  training  modules  including  ‘Infant  Feeding’  and  ‘Diabetes  in  Pregnancy’  to  support 
safe, informed care across maternity and neonatal services.   

You  raised  specific concerns  that  there  is  no  routine echocardiogram of  babies born  to a 
mother with diabetes and that in Esme’s case, although her mum’s identical twin had a  

heart defect,  this did not  trigger the protocol for a  routine  echocardiogram.  NHS  England 
encourages all trusts to follow the FASP criteria for offering screening for fetal anomalies. 
Additional screening  for fetal anomalies  may  include  a  fetal medicine  scan  and/or a  fetal 
echocardiogram for patients at higher risk of fetal anomalies for reasons such as maternal 
diabetes, or having a first degree relative with a congenital heart disease (for example an 
affected parent or sibling). We agree that additional screening for Esme would have been a 
reasonable course of action, given the increased risk associated with a genetically identical 
maternal aunt with a heart defect. However, this decision would have been down to individual 
risk  assessment  and  the  discretion  of  the  treating  clinician.  In  addition,  Esme’s  postnatal 
course would have been a further opportunity to diagnose a congenital heart defect, and we 
recognise that this monitoring was not as rigorous as it should have been in her case.   

You  also  raised  concerns  around  the  fact  that  the  usual  abnormality  scan  did  not  detect 
Esme’s  heart  defect.  The  diagnosis  of  ventricular  septal  defects  (VSD)  is  recognised  as 
difficult  on  prenatal  imaging  especially  without  the  use  of  colour  Doppler,  which  is  not  a 
requirement  of  the  cardiac  protocol.  We  agree  that  this  needs  to  be  improved  and  NHS 
England is therefore working in collaboration with Fetal Cardiologists, a Congenital Heart  

Disease Clinical Reference Group, and Congenital Heart Disease Operational Delivery  

Networks to improve detection of congenital cardiac conditions that are defined in the FASP 
standards,  by  providing  better  feedback  (including  data)  to  ultrasound  practitioners  and 
education and training of the ultrasound workforce.  

 Your report also flagged that the cardiac part of an abnormality scan is not audited in England 
under national guidance and cardiac images are not stored, meaning they are not available 
for subsequent examination. Currently there is no NHS FASP requirement to archive images 
of the fetal cardiac protocol. We acknowledge your concern and NHS England are currently 
reviewing this and, if required, will revise current guidance on the storage of cardiac views 
at the 20-week screening scan.  

There  are  two  national  audit  data  collections  of  antenatal  congenital  heart  disease,  the 
National  Congenital  Heart  Disease Audit  (NCHDA)  and  the  National  Congenital Anomaly 
and Rare Disease Registration Service (NCADRS). The NCHDA is a national data collection 
that produces an annual report of outcomes following congenital cardiovascular procedures. 
These  reports  include  a  proportion  of  patients  undergoing  surgery  or  intervention  for  a 
particular diagnosis that have an antenatal diagnosis. For 2023/24 this showed that 52% of 
infants  requiring  a  procedure  during  the  first  year  of  life  had  an  antenatal  diagnosis. The 
NCADRS  provides  national  surveillance  for  congenital  anomalies  ascertaining  data  from 
multiple pre and postnatal sources to evaluate detection rates.  

You also flagged concerns around the fact that centile tracking was not seen as useful before 
1 month of age. You also flagged concerns around the red book not being used to look at 
weight centile tracking in the early stages, even though tracking weight from an early point 
helps  ascertain  if  there  is  a  significant  issue  with  feeding.  We  agree  that  weighing  and 
measuring is an important part of monitoring a baby’s health and development, and that this 
could  have  been  improved  in  Esme’s  case.  The  Royal  College  of  Paediatrics  and  Child 
Health has developed guidance for healthcare professionals on the use of growth charts and 
measuring and weighing babies. It is important that babies are weighed in their first week of 
life,  as  part  of  the  assessment  of  feeding,  and  after  that  as  needed.  Once  feeding  is 
established, babies should usually be weighed at around 8, 12 and 16 weeks and 1 year at 
the time of routine immunisations. We recognise that the red book is an important tool for 
tracking and sharing information between healthcare professionals, and we are digitalising 
the red book to improve access to this data. Over time, we will add more information and 
create more functionality, including AI analytics, to ensure the best care is provided for the 
child, including detecting any anomalies in weight gain or feeding.  

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

Yours sincerely,   

PARLIAMENTARY UNDER-SECRETARY OF STATE FOR  
PATIENT SAFETY, WOMEN’S HEALTH AND MENTAL HEALTH

Date: 29 August 2025 

Private & Confidential 
Ms Alison Mutch 
Senior Coroner for the area of Manchester South 
Manchester City Coroner’s Office & Court 
Exchange Floor 
The Royal Exchange Building  
Cross Street  
Manchester M2 7EF 

Dear Ms Mutch 

Re: Regulation 28 Report to Prevent Future Deaths – Esme Vera Louise Atkinson 

Thank you for your Regulation 28 Report dated 6 June 2025 regarding the sad death of Esme Vera 
Louise Atkinson. On behalf of NHS Greater Manchester Integrated Care (NHS GM), We would like to 
begin by offering our sincere condolences to Esme’s family for their loss. 

Thank you for highlighting your concerns during the inquest which concluded on the 8 May 2025. On 
behalf of NHS GM, I apologise that you have had to bring these matters of concern to our attention. I 
recognise it is very important to ensure we make the necessary improvements to the quality and safety 
of future services.   

During the inquest you identified the following cause for concern: - 

The inquest heard evidence that health visitors / midwives and GPs play a key role in the 
early identification of a heart defect such as Esme’s at an early stage. Such a defect will 
rarely be apparent at the 72 hour check on the evidence given at the inquest but 
symptoms will manifest subsequently. Such symptoms can be subtle and the inquest was 
told that for there to be early suspicion, of a heart defect, training for community 
midwives/health visitors and GPs needed to be improved and good quality information 
sharing was also essential. This should include concerns around feeding and weight loss. 

The GP check at 6- 8 weeks was a key checking point but needed to be informed by asking 
all of the right questions and a good understanding of how to listen for such a heart 
defect. 

The inquest was told that it was important that it was understood by health professionals 
involved in the care of a baby that the mother being diabetic increased the risk of a defect 

4th Floor, Piccadilly Place, Manchester  M1 3BN   
Tel: 0161 6257791  www.gmintegratedcare.org.uk 

 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
 
 
 significantly and should increase the care taken in relation to presenting symptoms. 

There was no routine echocardiogram of a baby born of a mother with diabetes nationally 
although their risk of a defect was significantly higher than other babies and such a test 
would detect a baby with a ventricular septal defect at an early stage. 

In Esme’s case although her mum’s identical twin had a heart defect this did not in the 
North West, trigger the protocol for a routine echocardiogram. A heart defect in her 
mother would have. It was unclear why this was excluded given the genetic link. 

Esme had the usual abnormality scan which the inquest was told did not detect the defect 
on her heart. The inquest was told that the cardiac part of the abnormality scan was not 
audited in England under national guidance and the cardiac images were not stored. This 
meant they were not available for subsequent examination. 

The evidence of the paediatricians at the inquest was that tracking weight on the centile 
chart even from an early point assisted in understanding if there was a significant issue in 
relation to feeding triggering professional curiosity. However the evidence from the Health 
Visitor appeared to suggest that centile tracking was not seen as useful before 1 month 
and the red book was not used to look at weight centile tracking in the early stages.   

I have liaised with colleagues in the division of Women and Children at Stockport NHS Foundation Trust 
(SFT) and understand that there is nothing specific regarding training for early suspicions relating to 
heart defects within regular / mandatory training that we are aware of for the midwifery staff. It does not 
appear that there is anything within student training but will make enquires with the university syllabuses.  

All midwives are trained to escalate to a senior medical professional if they have any concerns or there 
are any deviations from the normal throughout the perinatal period, such as concerns based on failure to 
thrive, feeding issues or weight loss. 

I understand that:  

•  All providers have clear guidelines on escalation pathways 
•  All providers have clear guidelines on appropriate escalation of any abnormalities detected on 

scan during the pregnancy 

•  All midwives complete an initial APGAR (Appearance, Pulse, Grimace response, Activity, 

Respiration) review & top to toe examination – this would include escalation to the neonatal team 
for any colour, respiratory or tone concerns 

•  All babies receive a Neonatal Examination of the Newborn (NIPE) examination within 72 hours of 
birth. This includes auscultation of the heart, checking the femoral pulses & completing Oxygen 
Saturations. Any deviations from normal findings requires escalation to the Neonatal team for 
further review 

•  All providers are required to monitor weight gain in newborn infants and will have a policy in place 

to support escalation & referral if this is outside of normal limits 

•  All providers have an infant feeding guidance in place to support ‘reluctant feeders’ and ensure 

appropriate onward escalation where deviations from the norm occur 

•  All midwives follow a postnatal visit schedule prior to transfer of care to the Health Visitor which 
includes full examination of the newborn infant and direct links back into the neonatal pathways 
should there be any deviations from the normal 

4th Floor, Piccadilly Place, Manchester  M1 3BN   
Tel: 0161 6257791  www.gmintegratedcare.org.uk 

 
  
  
  
  
  
 
 
 
  
 All of the above guide staff to escalate with any concerns around heart defects. Additionally, the 
specialist NIPE training does detail specific training around heart defects, and is now included in all 
student midwives training, historically this was seen as specialist training completed by some midwives. 

Learning  

NHS GM is committed to learning from Prevention of Future Death reports. In response to this report, I 
will initiate the following actions: 

•  Develop with NHS GM clinical leadership and share a briefing for primary care providers to be 
distributed through the NHS GM primary care newsletter to remind primary care colleagues, 
especially GPs, of their role in the early identification of heart defects. 

•  Share your report and our response through the NHS GM Clinical Effectiveness Group (CEG) for 

wider system learning. 

•  Share your report and our response through the NHS GM Provider Oversight Meeting (POM) with 

Stockport NHS Foundation Trust. 

I will share the evidence of the above actions with you. 

I hope that my response addresses your concerns. Please contact me should you have any further 
enquiries. 

Best wishes 

4th Floor, Piccadilly Place, Manchester  M1 3BN   
Tel: 0161 6257791  www.gmintegratedcare.org.uk