Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0623, written 11 Dec 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Dec 2025 |
|---|---|
| Reference | 2025-0623 |
| Deceased | Izzah Ali |
| Coroner | Andrew Cox |
| Coroner area | Cornwall and the Isles of Scilly |
| Category | Child Death (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Information Classification: CONTROLLED NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. 2. , Chief Medical Officer, Royal Cornwall Hospital (for midwives, paediatricians and general medical learning) (for Health Visitors) 3. ICB – for circulation to Practice Managers at all GP practices in Cornwall. 4. CPFT – for clinicians in MIU settings 1 CORONER I am Andrew Cox, the Senior Coroner for the coroner area of Cornwall and the Isles of Scilly. 2 CORONER’S LEGAL POWERS 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. 3 INVESTIGATION and INQUEST On 9/12/25, I concluded the inquest into the death of Izzah Fatima Ali who died on 7/9/24 at the age of 9 months. I recorded the cause of death as: 1a Acute on chronic decompensated heart failure 1b Cardiomyopathy 1c Iron deficiency anaemia (treated with a blood transfusion) I recorded a conclusion that Izzah died from complications caused by her treatment for profound iron-deficiency anaemia in turn due to her consumption of cow’s milk. A copy of my full judgment is available upon request. 4 CIRCUMSTANCES OF THE DEATH Izzah was a nine-month-old female infant who had been born fit and well. Both of her parents came from Pakistan and her mother had only been in England for a couple of months before her daughter was born. She did not speak English. 1 Information Classification: CONTROLLED An interpreter was not used at ante-natal interactions contrary to guidance. A guide to feeding your baby was produced in English only and it did not set out that providing cow’s milk to an infant under the age of one was contra-indicated because it ran the risk of causing iron- deficiency anaemia. A UNICEF guide that was available in Urdu and which explained this was not provided. There were two health visitor attendances again without an interpreter present. At the time of the second attendance, Izzah was still breast-fed only. Unaware of the risks of using cow’s milk, Izzah’s parents provided this to their daughter believing it would be beneficial to her. There were multiple interactions with a wide variety of different healthcare professionals when it was noted Izzah was being breast and bottle fed. No inquiry was made to check that bottle fed meant formula fed or otherwise to establish what was in the bottles being given to Izzah. It was not identified that she was receiving cow’s milk until her last admission to hospital. On 6 August 2024, Izzah was seen in a Minor Injuries Unit and then referred to paediatric colleagues in Royal Cornwall Hospital. At that time it is more likely than not that she had developed anaemia and this was the cause of her pallor and distended abdomen. A urine dipstick confirmed a urinary tract infection and antibiotics were prescribed. The anaemia was not diagnosed. On 6 September 2024, Izzah was re-admitted into Royal Cornwall Hospital. It was established that she was profoundly anaemic. She needed to be treated by transfusion and this was undertaken. Izzah had a collapse and suffered cardiac arrests. She could not be resuscitated and was verified deceased on 7 September 2024. 5 CORONER’S CONCERNS During the course of these inquests, the evidence has 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 are as follows. 1) A theme that emerged during the evidence was the repeated reference to Izzah being ‘bottle-fed’ without further inquiry. In this country, bottle-fed infers ‘formula-fed’ but it is a presumption and in this case it was a wrongly assumed presumption. As one witness observed: ‘bottle-fed’ does not explain what was in the bottle. It could be a formula preparation, equally, it could be expressed breast milk. In this case, it was cow’s milk but until Izzah’s last admission into hospital no healthcare professional established that 2 Information Classification: CONTROLLED crucial fact. That reflects a failure to recognise that ‘bottle-fed’ is an incomplete description and requires an additional question of what is in the bottle. It also reflects a lack of appreciation around different cultural practices: while it may be assumed that cow’s milk would not be given to an infant under one in this country, it does not automatically follow that the same is true in other countries, for example, Pakistan. There was, in my judgment, an element of assumption made here which could alternatively be described as a lack of professional curiosity. - A second concern that emerged was that during both ante- and post-natal visits to a woman who did not speak English, no interpreter was involved, contrary to guidance. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] have the power to take such action. It is right that I acknowledge significant steps have already been taken by some of the recipients of this report. In particular, I note the Enhanced Care Pathway now introduced at RCHT. Nevertheless, I considered the learning that came out from this inquest to be so fundamental and of such wide application that I wanted to ensure it reached all HCPs in the county. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 8/2/2026. 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 and to the following Interested Persons: Next of kin Royal Cornwall Hospital - - - Cornwall Partnership Foundation Trust - Cornwall Council - I am also under a duty to send the Chief Coroner a copy of your responses. 3 Information Classification: CONTROLLED 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 [DATE] [SIGNED BY CORONER] 10/12/25 4
3 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.
Cornwall Council Information Classification: CONTROLLED Mr Andrew Fox Senior Coroner for Cornwall & the Isles of Scilly H.M Coroner’s Office Pydar House Pydar Street Truro Cornwall TR1 2AY reference Date: 4th February 2026 Dear Mr Fox RESPONSE TO REGUALTION REPORT TO PREVENT FUTURE DEATHS This formal response addresses your report submitted under paragraph 7, Schedule 5 of the Coroners and Justice Act 2009, and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, dated December 10, 2025. The report follows the tragic death of Izzah Fatima Ali, who passed away at 9 months old on September 7, 2024. Firstly, we wish to reiterate our deepest condolences to Izzah’s family. We acknowledge the significant implications of this case and the seriousness of the concerns expressed by the coroner. It is acknowledged that, during the inquest into the death of Izzah Fatima Ali, the evidence presented identified the following matter of concern: • I wanted to ensure that the authors of the Essential Guide to feeding your Baby that I was told was being re-produced were aware of the facts of this case. I wanted them to reflect on whether the revised Guide needed to state that giving cow’s milk to an infant under the age of one was not advised because it ran the risk of preventing the absorption of iron from other sources and causing anaemia. I would like to assure you and the family of Izzah Fatima Ali that we have thoroughly reviewed the concerns raised in the Regulation 28 report and have either implemented or planned the actions detailed below. Funding secured for rapid mitigations • Public Health has agreed to repurpose a £65,000 PHN underspend, enabling: £35k to rewrite/update the ‘Essential Guide to feeding and caring for your Cornwall Council | Konsel Kernow New County Hall, Treyew Road, Truro, TR1 3AY T: Cornwall Council Information Classification: CONTROLLED baby’ (including content on risk of animal milk/iron deficiency and translation to priority languages) and ~£30k to strengthen interpreter/translation solutions across the service. Essential Guide — update implemented • The Essential Guide to feeding and caring for your baby (digital version) has been updated (December 15, 2025) to include explicit guidance on use of animal milk as a main drink and iron deficiency risk. This has been updated on the website and PDF version, and this can be translated to other languages using ‘Recite Me’ on the website. A new fully updated version will be written by the Specialist Health Visitor for infant feeding for Cornwall Council in collaboration with health colleagues, and this will be available in print as well as a digital version. Staff training and mandatory webinar • A mandatory Infant Feeding webinar for all staff has now taken place, this included cultural baby feeding practices, professional curiosity and the use of professional interpreters. Staff that did not attend due to days off, annual leave, sickness etc. have been asked to watch the recorded webinar and sign to say that this has taken place. This will also include staff from other services who may be in contact with children who are bottle feeding, i.e., Core Parenting team, Family Hub staff etc. • All staff across the service have been asked to complete their refresher training on cultural capabilities. • We have also arranged for an all-staff webinar on cultural awareness. • A Learning from Experience safeguarding webinar has also taken place from our safeguarding team within Public Health Nursing, this has included the process of attending coroner's court and also discussed the issues raised not only from our service but any learning that may have an impact on our service or that we can learn from. Policy/Standard Operating Procedure alignment on interpreter/translator services across the organisation • A meeting has taken place with the resettlement team within Cornwall Council on January 23, 2026. Within this meeting we discussed how we can make any improvements and work closely together to ensure we are meeting the needs of families where English is not their first language. Draft Standard Operating Procedure (SOP) on Interpretation and Translation has been updated to reinforce professional use of interpreters and safeguard practice which also includes the importance of documenting need in record. External best practice initiated • Our South West, Department of Health and Social Care representative, from the Department of Health and Social Care. Health and Wellbeing Programme Cornwall Council | Konsel Kernow New County Hall, Treyew Road, Truro, TR1 3AY T: Cornwall Council Information Classification: CONTROLLED Manager for Maternity Children and Young People has reached out nationally to horizon scan national practice on translator services across Health Visiting and School Nursing and has shared examples of good practice, this can then be added to the updated SOP. • We have met with the Senior Clinical Lead from the 0-19 Clinical Programme Unit from the Department of Health and Social Care to discuss terminology and advice regarding bottle feeding, and there has been no change nationally to the term bottle feeding. We will be providing further guidance and training to staff through the webinars arranged regarding professional curiosity in relation to formula/bottle feeding and we have updated all training that is provided in relation to infant feeding. The following time frame has been put in place: 0-4 weeks (risk reduction) • The Essential Guide to feeding and caring for your baby (digital version) has been updated with translated versions available. • Deliver mandatory webinar focusing on language/terminology, professional curiosity, and safe formula guidance by the end of January 2026. • Confirm interpreter pathway and procurement/enablement options using the draft SOP as baseline. 1-3 months (embed) • Finalise Interpretation SOP and publish, provide service wide training to all staff. • Audit and Quality Assurance: add targeted checks on “what’s in the bottle” recording and interpreter usage. • Communication to partners: harmonise terminology and advice; share Essential Guide update and SOP highlights. 3-6 months (assurance and demonstrate impact) • Post‑implementation review: measure webinar completion, training compliance, interpreter bookings, and incidents. • Parent‑facing assurance: update Family Hubs and Advice Line staff; align with national initiatives. • A fully updated version of the Essential Guide will be produced within the next 4-6 months using underspend from Public Health Nursing. Cornwall Council | Konsel Kernow New County Hall, Treyew Road, Truro, TR1 3AY Cornwall Council Information Classification: CONTROLLED I hope I have provided reassurance to you and the family of Izzah Fatima Ali about the learning that has and will continue to take place as a consequence of her sad death. Yours sincerely Head of Service, Best Start Community Health and Wellbeing MSc, Health and Care System Leadership, BSc (Hons), Specialist Community Public Health Nurse- Health Visitor. Registered Nurse, CMgr FCMI Cornwall Council | Konsel Kernow New County Hall, Treyew Road, Truro, TR1 3AY
Sarah James
Chief Improvement Officer
Carew House
Beacon Technology Park
Dunmere Road
Bodmin
Cornwall
PL31 2QN
9th February 2026
Dear Mr Cox.
Re: Izzah Ali deceased
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 10
December 2025, concerning the death of Izzah Fatima Ali who died on 7 September
2024 at the age of 9 months.
In advance of responding to the specific concerns raised in your Report for Cornwall
Partnership NHS Foundation Trust (“The Trust”), we would like to express again our
deep condolences to Izzah’s family for their loss.
Your concern for the Trust was that “There were multiple interactions with a wide
variety of different healthcare professionals when it was noted Izzah was being breast
and bottle fed. No inquiry was made to check that bottle fed meant formula fed or
otherwise to establish what was in the bottles being given to Izzah. It was not identified
that she was receiving cow’s milk until her last admission to hospital.
Head office: Carew House, Beacon Technology Park, Dunmere Road, Bodmin, PL31 2QN.
Telephone: 01208 834 600. Matthew Taylor, Chair. Debbie Richards, Chief Executive.
On 6 August 2024, Izzah was seen in a Minor Injuries Unit and then referred to
paediatric colleagues in Royal Cornwall Hospital. At that time, it is more likely than not
that she had developed anaemia, and this was the cause of her pallor and distended
abdomen”.
Following part 1 of the inquest, the Trust took the opportunity to explore the concerns
raised in evidence which involve the minor injury unit’s involvement and learning in
this very sad case.
It was suggested in evidence that the Trust may wish to consider whether clinicians
may query what parents may be feeding their babies and whether this is breast milk,
cow’s milk or formula. The Trust’s General Practitioner said in evidence, that he was
content with the actions of escalation taken at the time of his consultation, however, in
future, from an individual clinician’s perspective, he would query the content of the
bottle, if a similar situation were to occur.
The Trust agrees that where nutrition may relate to the cause of an attendance at a
Minor Injuries Unit, or any healthcare setting, it would be entirely appropriate to make
further enquiries about the content of the bottle.
Actions taken:
Our Minor Injuries Unit staff have asked to ensure that, should there be any concern
about a child’s nutrition and if it is considered this could be linked to an attendance,
staff should ask for specific details, including what is being fed.
Staff have also been reminded that children attending our Minor Injuries Units should
be weighed on each visit as a standard process, and this should be documented in
the clinical records. For children aged 2 years and under, this should also be recorded
by staff in the child’s red book, if it is available.
Page 2
Additionally, a reminder has been shared with all Minor Injuries Unit staff that if there
are any concerns that nutrition may relate to the cause of an attendance, they should
ask for the child’s red book to be presented at that or any future visit.
Thank you for bringing these important concerns to the Trust’s attention and please
do not hesitate to contact us should you need any further information.
Yours sincerely,
Chief Improvement Officer
Page 3
Chief Medical officer’s office
Royal Cornwall Hospital
Truro
Cornwall
TR1 3LJ
Date: 2 February 2026
Private and Confidential
Mr. Andrew Cox
H.M Senior Coroner for Cornwall and the Isles of Scilly
Pydar House
Pydar Street
Truro
Cornwall
TR1 1XU
Dear Mr Cox,
Re: The Late Izzah Fatima Ali – Regulation 28 PFD Report and Response
I write in response to the Regulation 28 Report to Prevent Future Deaths, dated 09 December 2025
and received on the 10 December 2025. This was issued following the inquest into the death of Izzah
Ali which was heard over 17-18 November 2025 and concluded on 09 December 2025.
I would like to take this opportunity to express my sincerest condolences to the family of Izzah Ali for
their tragic loss.
During the inquest, the evidence revealed matters giving rise to concern. Which are as follows:
1. There was a failure to recognise that ‘bottle fed’ is an incomplete description and requires an
additional question of ‘what is in the bottle?’ – there was a lack of professional curiosity
2. During ante-natal and post-natal visits with a woman who did not speak English, no
interpreter was involved, contrary to guidance.
Please find below the response from the Trust and details of the actions taken in relation to the
above concerns.
Response:
1. Izzah’s case has been widely shared across the organisation and has increased professional
awareness, knowledge and confidence in asking the appropriate question on feeding in
infants.
The Emergency Department are to change their language when asking parents about how
babies are fed from ‘bottle’ to ‘formula’ – e.g. ‘is your baby formula or breast fed?’ In addition,
ED documentation in terms of proformas for paediatric clerking in the ED by both medical
and nursing staff will reflect this change.
In relation to our paediatric team, completion of routine enquiry will be embedded into the
admission proforma use for our inpatient children’s ward. “What is in the bottle?” has become
a standard enquiry for us all in paediatrics and will be included in their admission
documentation. Support can then be provided for families if indicated.
Maternity services use routine enquiry about the exact nature of bottle feeding as a
mandatory question at every safe opportunity making the identification of need or risk earlier.
2. I reiterate the contents of paragraphs 9 – 11 from
statement dated 3
September 2025 (Interim Director of Midwifery at time of signing, now Director of Midwifery)
which was produced into evidence at the hearing on 17 November 2025. Since Izzah’s tragic
death, the Trust has already undertaken and has in place the following:
a. Enhanced Continuity Pathway developed and implemented
b. Pregnancy Circles implemented with face-to-face translators
c. Strengthened interpreter and language support in maternal care
d. Audits of interpreter and language support will be reported to the Clinical Audit Assurance
software (AMaT) and through Perinatal Safety Trust Board report. This commenced in
January 2025 and will continue to be audited every 3 months.
I hope that this letter provides both you and Izzah’s family with assurance that the Trust has taken
seriously the concerns raised in your report and that the Trust has taken the appropriate action to
prevent future deaths.
Yours Sincerely
Chief Medical Officer
Royal Cornwall Hospitals NHS Trust
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