Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0358, written 15 Jul 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 15 Jul 2025 |
|---|---|
| Reference | 2025-0358 |
| Deceased | Alfie Lydon |
| Coroner | R Brittain |
| Coroner area | Inner North London |
| Category | Child Death (from 2015) · Community health care and emergency services related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: , Chief Midwifery Officer, NHS England via ; , President, Royal College of Paediatrics and Child Health via 1 CORONER I am R Brittain, Assistant Coroner for Inner London North. 2 CORONER’S LEGAL POWERS 3 4 I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. INVESTIGATIONS and INQUESTS An investigation into the death of Alfie Lydon (date of birth 28/2/24) was opened on 26/3/24, following his death on 12/3/24. An inquest was opened on 18/4/24 and concluded on 27/6/25. The conclusion reached was that Alfie died from natural causes. CIRCUMSTANCES OF THE DEATH Alfie was admitted to hospital on 6/3/24 after being found profoundly unwell at home. He was subsequently transferred to another hospital for intensive care support but sadly died on 12/3/24 from a then unknown cause. A post mortem examination demonstrated that he died from the consequences of a viral infection. Prior to his admission to hospital, concerns had been raised by Alfie’s parents to the community midwife team regarding the adequacy of his feeding and increasing lethargy. On two occasions midwives discussed Alfie with the neonatal team at the local hospital but admission was not felt to be necessary. These discussions were not documented by the hospital doctors who took the calls and, on one occasion, not documented by the midwife who made the call. As such, it was difficult to identify who provided advice to the midwives and the rationale for the decision-making process. Ultimately, given the overwhelming nature of the infection Alfie suffered from, I concluded that it was not likely earlier admission would have prevented his death. 5 CORONER’S CONCERNS 1 During the course of this inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN following the inquest into Alfie’s death were as follows: 1. I heard evidence that the vast majority of hospital Trusts do not have processes in place to document external calls from midwives to hospital teams. Concerns were raised that this can result in a lack of continuity and escalation of care, particularly with regards to parental concerns. The hospital Trust involved has taken steps to document such calls now but this is undertaken on paper, which is subsequently uploaded to the hospital records. They plan to implement an electronic solution but not for some time. There is a concern that a lack of contemporaneous, accurate and immediately available documentation of discussions between community and hospital teams could result in deaths in future similar circumstances. Given that this is not simply a local issue, this concern warrants raising at a national level. 6 ACTION COULD BE TAKEN In my opinion action could be taken to prevent future deaths and I believe that the addressees have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 9 September 2025. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner, the Lydon family, the hospital Trusts, the Department of Health and Social Care and the CQC. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. She may send a copy of this report to any person who she believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 15 July 2025 Assistant Coroner R Brittain 2
2 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
HM Assistant Coroner R Brittain
Inner North London
St Pancras Coroner’s Court
Camley Street
London
N1C 4PP
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
4th September 2025
Dear Coroner,
Re: Regulation 28 Report to Prevent Future Deaths – Alfie Lydon who died on
12 March 2024.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 15 July
2025 concerning the death of Alfie Lydon on 12 March 2024, sent to NHS England’s
Chief Midwifery Officer. I am responding on behalf of the organisation in my capacity
as National Medical Director but would like to assure you that the Chief Midwifery
Officer has also been sighted on this response and reviewed your Report.
In advance of responding to the specific concerns raised in your Report, I would like
to express my deep condolences to Alfie’s parents and wider family. NHS England is
keen to assure the family and yourself that the concerns raised about Alfie’s care have
been listened to and reflected upon.
Your Report raised the concern that the vast majority of hospital trusts do not have
processes in place to document external calls from community midwives to hospital
teams, and that this can result in a lack of continuity and escalation of care, particularly
regarding parental concerns.
With regard to documenting communication between community midwives and staff
working on acute sites, this would be a standard expectation in the provision of care
for both those making and those receiving the calls. Both staff groups will typically
utilise the relevant Trust’s Electronic Patient Record (EPR) system for either
community midwifery services or hospital maternity / neonatal services, depending on
which staff groups on the acute site are involved. This should allow them to record
information directly within the patient’s record, which should be accessible to all
system users regardless of setting. This is on the provision that the maternity service
has the necessary digital infrastructure, including capabilities for offline working when
in the community. Should this not be the case, Trusts should still ensure that they have
effective processes and procedures in place for the recording of key information within
the EPR and access for those caring for the patient.
Regardless of the EPR system in use, community midwives are expected to document
any conversation that they have with other healthcare professionals in the patient
notes, with the requirement for accurate documentation being a basic, core aspect of
clinical care. This is made clear in both the Nursing and Midwifery Council Standards
of proficiency for midwives and The Code, which describes professional standards of
practice for nurses, midwives and nursing associates. It would also be expected that
each organisation has a process to ensure that any community midwife notes are
brought together with the hospital maternity / neonatal notes, if this is not an automatic
feature of the digital system employed. In addition, the person receiving any call from
a health care professional should have a means of documenting any advice given in
the patient record.
Alfie’s case will be raised with the Neonatal Operational Delivery Networks and
Regional maternity teams, with the expectation that they subsequently cascade to all
maternity and neonatal units the importance of documenting such consultations.
The new Fit for the future 10 year health plan for England will also help address the
issues raised in your Report through its commitment to the introduction of a new Single
Patient Record (SPR), which will bring together all of a patient’s medical records into
one place. It is intended that the SPR will be rolled out in maternity care first, ensuring
that maternity teams have all of the information they need about previous
consultations, medical history and stated preferences, helping them to provide high
quality and personalised care.
NHS England’s National teams have also engaged with the East of England’s
Regional Chief Midwife on the concerns raised in your Report. They advise that:
• Currently, 46% of maternity units in the region have digital care records and the
expectation is that any discussions regarding clinical care are recorded in the
EPR.
• The remainder of maternity units are expected to have digital records in place
within the next 12 months.
• Some trusts within the region also use digital devices such as mobile phones
to record clinical care conversations.
• The concerns raised in your Report have been shared with maternity and
neonatal units across the region, with a reminder to staff to record discussions
on electronic records where available. Where not currently available, staff have
been asked to join up hand-held records with clinical records at the earliest
available opportunity.
I would also like to provide further assurances on the national NHS England work
taking place around the Reports to Prevent Future Deaths. All reports received are
discussed by the Regulation 28 Working Group, comprising Regional Medical
Directors, and other clinical and quality colleagues from across the regions. This
ensures that key learnings and insights around events, such as the sad death of Alfie,
are shared across the NHS at both a national and regional level and helps us to pay
close attention to any emerging trends that may require further review and action.
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
NHS England
Assistant Coroner R Brittain Inner North London 9 September 2025 Dear Assistant Coroner R Brittain, Re: RCPCH Response to the Inquest Touching the Death of Alfie James Lydon A Regulation 28 Report – Action to Prevent Future Deaths Thank you for sharing your report with us regarding the tragic and untimely passing of Alfie James Lydon. I was very sorry to hear of Alfie’s death. Colleagues at the college and I have considered your report carefully and note your concerns regarding a lack of processes in place to document external calls from midwives to hospital teams. We are pleased to note that the Trust involved has taken steps to rectify this. We note your continued concern this is undertaken on paper and is not simply a local issue. We also note and support your observation and concern that a lack of contemporaneous, accurate and immediately available documentation of discussions between community and hospital teams could result in deaths in future similar circumstances. Our Facing the Future: Together for child health standards state that ‘healthcare professionals assessing or treating children with unscheduled care needs in any setting have access to the child’s shared electronic record’. As a membership organisation we have no direct control over the mechanism(s) by which healthcare staff record their clinical communications. Our sphere of influence lies in nudging change at national level. Currently, there is a lack of legislation and guidance on exactly what information, when and how it should be shared between agencies. In practice, our members (paediatricians) have reported difficulties in exchanging information, which may be a result of poor communication between professionals and/or a lack of interoperable information systems available to effectively share information. Use of the NHS number as a single unique identifier for children will overcome these barriers and enable information to be shared more easily between agencies and services. This is something RCPCH have long campaigned for and will continue to do so as we see implementation of the new NHS 10 Year Plan. We agree with your observation and concern that a lack of record keeping can lead to a lack of continuity and escalation of care, particularly with regards to parental concerns. RCPCH are actively supporting the role out of Martha’s Rule, an inpatient safety initiative currently being piloted in England which aims to empower all staff, patients and their families to seek an independent medical review if they feel their concerns about a patient’s care are not being adequately addressed. The rule is designed to give families the ability to directly request an expert review by a senior clinician not within the immediate care team, potentially identifying critical issues before they result in harm. By establishing this right to an independent review, Martha’s Rule improves ability to recognise and respond to deterioration by incorporating parents and families as part of the team. It formalises an escalation route for parents, carers and families to use to ensure their concerns are listened to and acted on and encourages transparency and collaboration. RCPCH contributed to the early working groups for Martha’s Rule and we continue to engage with NHS England as data from the pilot sites emerge. Martha’s Rule does not extend into the community at present, but learnings from Martha’s Rule could in future be applied in the community setting. Thank you for seeking our views and reminding us of the importance of this work. Our sincere condolences are with Alfie’s family. Yours sincerely RCPCH President
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