Includes failures of neonatal-resuscitation competence arrangements, including insufficient clinical exposure, training, simulation, supervised practice, refresher provision, competence assessment or assurance for paediatricians, neonatal clinicians and other staff expected to perform or support neonatal resuscitation.
What is not included
Excludes adult or general resuscitation competence concerns where neonatal resuscitation is not materially involved.
Excludes generic first-aid, emergency-response or staff-training deficiencies without a direct neonatal-resuscitation connection.
Excludes shortages or unavailability of neonatal resuscitation equipment where clinician competence is not the deficient control.
Excludes failures in neonatal diagnosis, treatment or referral that do not concern competence to perform or support neonatal resuscitation.
Trends
Reports over time
Reports mentioning this concern, over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Royal College of Paediatrics and Child Health2
Bedfordshire Hospitals NHS Foundation Trust1
Care Quality Commission1
Department of Health and Social Care1
East Kent Hospitals University NHS Foundation Trust1
General Medical Council1
NHS England1
North West Anglia NHS Foundation Trust1
Recipient name withheld1
Royal College of Obstetricians and Gynaecologists1
NHS trust3
Professional body2
Executive non-departmental public body1
Health and care professional regulator1
Health and social care service regulator1
Health professional body1
Ministerial department1
Type not available1
Reports and published responses 5 reports
See individual reports that have raised this concern, and the actions taken in response
Manchester South
Concerns raised1
Lack of compulsory direct observed training for paediatric middle grades performing neonatal intubation
Linked response
Royal College of Paediatrics and Child Health
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Royal College of Paediatrics and Child Health
Provide neonatal airway management training through Progress+ neonatology placements.
Royal College of Paediatrics and Child Health
Strengthen the Progress+ curriculum's neonatal airway capabilities, emphasizing non-invasive airway management and specialty-level safe intubation and difficult-airway management.
Royal College of Paediatrics and Child Health
Develop a neonatal airway safety standard with BAPM addressing skills maintenance and ongoing training.
Royal College of Paediatrics and Child Health
Signpost members to the neonatal airway safety standard and its skills-maintenance resources.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Royal College of Paediatrics and Child Health
Removing mandatory neonatal intubation DOPS does not necessarily increase risk because non-invasive airway management is safer and the former DOPS provided false reassurance.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Royal College of Paediatrics and Child Health
Operational delivery networks are responsible for supporting airway and resuscitation skill maintenance across neonatal units, particularly where skills are infrequently used.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester South
Concerns raised2
Reduction in paediatric middle grades' practical experience in neonatal resuscitation
Lower level of consultant general paediatricians' experience in complex neonatal resuscitation
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
Royal College of Paediatrics and Child Health
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Royal College of Paediatrics and Child Health
Require all core trainees to spend time in a neonatal setting during training.
Royal College of Paediatrics and Child Health
Use a formal supervisor assessment to confirm trainee readiness for tier 2 rota work.
Royal College of Paediatrics and Child Health
Require general paediatric specialty trainees to spend time in a neonatal setting.
Royal College of Paediatrics and Child Health
Maintain mandatory specialty-level capabilities for neonatal resuscitation and airway management.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Royal College of Paediatrics and Child Health
Specific mandatory neonatal placements are unnecessary because capabilities can be acquired in most settings, with all trainees spending time in a neonatal setting.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Royal College of Paediatrics and Child Health
Mandatory non-invasive airway skills, readiness assessment, consultant support and current Newborn Life Support status provide safe preparation for neonatal resuscitation.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Cambridgeshire and Peterborough
Concerns raised1
Lack of training on blood transfusion during neonatal resuscitation
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
North West Anglia NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
North West Anglia NHS Foundation Trust
Adopt a low threshold for blood transfusion during resuscitation, preferring blood boluses over fluids in line with 2021 NLS guidance.
North East Kent
Concerns raised1
Inadequate neonatal resuscitation training
This report raised 19 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Department of Health and Social Care
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Department of Health and Social Care
The Trust is responsible for setting out and implementing actions to address the identified maternity-service safety risks.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Bedfordshire and Luton
Concerns raised1
Failure to provide further support to midwives without experience in newborn resuscitation
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Bedford Hospital
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Bedford Hospital
Require all employed midwives to complete annual neonatal resuscitation theory and simulation training under accredited trainers.
Bedford Hospital
Provide new starter midwives with a structured orientation period, nominated preceptor and managerial and supervisory support tailored to learning needs.
Bedford Hospital
Risk-assess case complexity at handover and throughout each shift, allocate women according to staff experience and competence, and record four-hourly reviews.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Bedford Hospital
Existing training, orientation, supervision and emergency support systems sufficiently address risks from limited hands-on neonatal resuscitation experience.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Bedford Hospital
A second person is not required at birth; midwives must request support when clinically necessary, with assistance available through existing arrangements.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.