3 Jun 2025 Benjamin Finch Arnold · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 6 Unequal provision of maternity services between LGI and SJUH View source Ambiguity about the classification and operating parameters of the SJUH maternity unit View source Limited nursing and medical support available to the SJUH site View source Lack of standardised guidelines for performing LISA procedures View source Insufficient national guidelines for identifying and treating reversible causes of cardiac arrest in newborn babies View source Lack of on-site paediatric cover at SJUH View source See 3 more concerns
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AI-generated summary
Benjamin Finch Arnold · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Benjamin Finch Arnold was born prematurely at Saint James’ University Hospital after his mother was redirected there because the intended delivery unit was closed due to lack of capacity. He developed breathing difficulties during a LISA procedure, suffered bilateral pneumothoraces and a subsequent right-sided tension pneumothorax, and died after a devastating brain injury caused by prolonged low oxygen levels. The concerns included the organisation and classification of maternity services, the lack of standardised guidance for LISA procedures and newborn cardiac arrest, and updates to the hospital risk register.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Association of Perinatal Medicine; that does not assign responsibility.
PFD Monitor interpretation Unequal provision of maternity services between LGI and SJUH
Wider context from the report “(1) The provision of maternity services across the Leeds Teaching Hospitals Trust (LTHT) continues to be split unequally between LGI and SJUH , with, for example, no on-site paediatric cover at SJUH. What was described by LTHT witnesses as the “isolation” of the SJUH site, particularly as it related to the limited nursing and medical support that can be called upon, was a recurrent theme in the inquest. The inquest was told that a long held ambition to bring LTHT’s maternity services under one roof had been recently frustrated by the announcement that the building of a new hospital for Leeds would not begin until 2030. Secretary of State for Health and Social Care to respond.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Association of Perinatal Medicine; that does not assign responsibility.
PFD Monitor interpretation Ambiguity about the classification and operating parameters of the SJUH maternity unit
Wider context from the report “(2) The evidence at the inquest disclosed an ambiguity as to whether the SJUH maternity unit, officially a “Level 1” centre, was operating outside the parameters of that classification . That ambiguity was demonstrated by a witness (whose evidence was admitted in writing under R23 due to her poor health) who described it as a “Level 2” unit , and by a witness in person who described it as a “Level 1 and a half” unit, which last classification does not exist . LTHT to respond.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Association of Perinatal Medicine; that does not assign responsibility.
PFD Monitor interpretation Limited nursing and medical support available to the SJUH site
Wider context from the report “(1) The provision of maternity services across the Leeds Teaching Hospitals Trust (LTHT) continues to be split unequally between LGI and SJUH, with, for example, no on-site paediatric cover at SJUH. What was described by LTHT witnesses as the “isolation” of the SJUH site, particularly as it related to the limited nursing and medical support that can be called upon , was a recurrent theme in the inquest. The inquest was told that a long held ambition to bring LTHT’s maternity services under one roof had been recently frustrated by the announcement that the building of a new hospital for Leeds would not begin until 2030. Secretary of State for Health and Social Care to respond.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Association of Perinatal Medicine; that does not assign responsibility.
PFD Monitor interpretation Lack of standardised guidelines for performing LISA procedures
Wider context from the report “(3) The evidence disclosed concerns that guidelines for the performing of a LISA procedure are not standardised across the NHS , particularly with reference to the performing of a chest x-ray to exclude pneumothorax before commencing the procedure , and to the necessity of seeking consultant approval before undertaking the procedure . BAPM, RCPCH, RCUK and NN all to respond.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Association of Perinatal Medicine; that does not assign responsibility.
PFD Monitor interpretation Insufficient national guidelines for identifying and treating reversible causes of cardiac arrest in newborn babies
Wider context from the report “(4) The evidence disclosed concerns whether national guidelines on the reversible causes of cardiac arrest (the “4 H’s and 4 T’s”) were sufficient for the purposes of identifying and treating the potential causes of cardiac arrest in a newborn baby . BAPM, RCPCH, RCUK and NN all to respond.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Association of Perinatal Medicine; that does not assign responsibility.
PFD Monitor interpretation Lack of on-site paediatric cover at SJUH
Wider context from the report “(1) The provision of maternity services across the Leeds Teaching Hospitals Trust (LTHT) continues to be split unequally between LGI and SJUH, with, for example, no on-site paediatric cover at SJUH . What was described by LTHT witnesses as the “isolation” of the SJUH site, particularly as it related to the limited nursing and medical support that can be called upon, was a recurrent theme in the inquest. The inquest was told that a long held ambition to bring LTHT’s maternity services under one roof had been recently frustrated by the announcement that the building of a new hospital for Leeds would not begin until 2030. Secretary of State for Health and Social Care to respond.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish multidisciplinary frameworks containing neonatal airway safety, LISA checklist, and consultant working-pattern recommendations.
Verbatim wording from the response “BAPM is an advisory, not an executive body. We have made some relevant recommendations in our frameworks for practice that can form the basis for local guidance. It is the responsibility of individual trusts to implement their own processes in line with national guidelines. The frameworks are published by a multidisciplinary team that deliver neonatal intensive care and after consultation with the whole BAPM membership and relevant associated speciality groups. The two frameworks for practice and one report that are relevant to the care given in this case are “Managing the Difficult Airway in the Neonate” published in October 2020, “Neonatal Airway Safety Standard” published in April 2024 and “Consultant Working Patterns – A BAPM Report” published in November 2023. I draw your attention to the fact that the latter two documents were NOT in place at the time of this death.” Source location Response from British Association of Perinatal Medicine
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Universal consultant approval before LISA is not necessary and may delay treatment; local teams should decide based on circumstances and experience.
Verbatim wording from the response “would be determined locally, dependent on clinical situation and the experience of the on-site team. A universal policy of seeking consultant approval before undertaking this procedure is not necessary and may delay delivery of LISA.” Source location Response from British Association of Perinatal Medicine
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Individual trusts are responsible for implementing local processes based on BAPM recommendations; BAPM is advisory rather than executive.
Verbatim wording from the response “BAPM is an advisory, not an executive body. We have made some relevant recommendations in our frameworks for practice that can form the basis for local guidance. It is the responsibility of individual trusts to implement their own processes in line with national guidelines. The frameworks are published by a multidisciplinary team that deliver neonatal intensive care and after consultation with the whole BAPM membership and relevant associated speciality groups. The two frameworks for practice and one report that are relevant to the care given in this case are “Managing the Difficult Airway in the Neonate” published in October 2020, “Neonatal Airway Safety Standard” published in April 2024 and “Consultant Working Patterns – A BAPM Report” published in November 2023. I draw your attention to the fact that the latter two documents were NOT in place at the time of this death.” Source location Response from British Association of Perinatal Medicine
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The national neonatal resuscitation algorithms' four Hs and five Ts cover the overwhelming majority of reversible causes of cardiac arrest.
Verbatim wording from the response “Resuscitation of the newly born infant is guided by the Resuscitation Council of the United Kingdom “Newborn Life support” algorithm. In addition, the Resuscitation Council of the United Kingdom “Paediatric Advanced Life Support Guideline” includes reversible causes of cardiac arrest (4 H’s and 5 T’s) in its algorithm. These algorithms are produced by a multidisciplinary team of experts and updated on a regular basis. They form the National recommendations to deliver neonatal resuscitation in the United Kingdom. Our view is that the list of 4 H’s and 5 T’s covers the overwhelming majority of reversible causes of cardiac arrest in the newborn infant.” Source location Response from British Association of Perinatal Medicine
Open published response
Concerns raised 1 Variability in on-call Neonatology Consultant attendance times View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Felix Burton HARTLEY · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Felix Burton Hartley was born without a heartbeat on 19 February 2023, was resuscitated after around 20 minutes without a heartbeat, and later could not recover from hypoxia and chorioamnionitis. The concern was that variable attendance times for the on-call Neonatology Consultant, covering two geographically separated hospitals, could create a risk of future deaths, although the report did not find the consultant’s attendance time causative or contributory to Felix’s death.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Association of Perinatal Medicine; that does not assign responsibility.
PFD Monitor interpretation Variability in on-call Neonatology Consultant attendance times
Wider context from the report “In this case, I heard that over the weekend and overnight Neonatology Consultants are not available immediately on site at either the Princess Royal Hospital, Haywards Heath or the Royal Sussex County Hospital in Brighton . I heard that on-call Consultants over the weekend are on site at Brighton for some of the period but for the majority they are contactable by telephone in the first instance only . I heard that the Trust position is that this is not unusual in many settings as Consultants are not intended to be the first responders to emergency calls.
At University Hospitals Sussex NHS Foundation Trust (“the Trust”), the on-call Consultant covers both the Princess Royal Hospital and the Royal Sussex County Hospital . These two sites are not close in proximity, and I heard that the traffic impacts on the time it would take for a Consultant to attend . The on-call Consultant does not always have access to an emergency vehicle and if called to attend either site would use their own vehicle and be subject to the usual road traffic laws . I heard that the Trust practice, as opposed to Policy, is that the on-call Consultant cannot be more than 30 minutes from either Brighton or Haywards Heath. The Trust facilitates accommodation at Brighton for the on-call Consultant so that they are within 30 minutes of Brighton if required.
I was told that the arrangements for Neonatal care at the Princess Royal are in accordance with the British Association of Perinatal Medicine guidelines and that there is no national guidance as to the time that an on-call Neonatology Consultant should be expected to attend a hospital in the event of an emergency or as to whether multiple sites can be covered by one on-call Consultant. Whilst I did not find the timing of the attendance of the on-call Consultant causative or contributory in relation to Felix’s death, I am concerned that the time period in which attendance is made may vary and create a risk of future deaths .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Recommend against simultaneous out-of-hours cover of geographically separate neonatal sites and concurrent Tier 2 and Tier 3 cover by one consultant.
Verbatim wording from the response “In our Service and Quality Standards for Provision of Neonatal Care in the UK (November 2022) [Page 24] we recommend;” Source location Response from British Association of Perinatal Medicine
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish recommendations requiring immediate consultant availability, attendance within 30 minutes, and robustly job-planned and risk-assessed local coverage arrangements.
Verbatim wording from the response “In a new document from November 2023 that was NOT in place at the time of this death, Consultant Working Patterns – A BAPM Report [page 5]” Source location Response from British Association of Perinatal Medicine
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation BAPM guidance contains no recommendation specifying the time consultants must be on site.
Verbatim wording from the response “The national terms and conditions for NHS consultants in England are set by NHS Employers and we have attached the latest version [Please see p18 and 40.] We have also attached A guide to Determining On-call Availability Supplements issued by the NHS Modernisation Agency (August 2004). There is no recommendation around the time required to be on site.” Source location Response from British Association of Perinatal Medicine
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation BAPM is advisory rather than executive and therefore cannot direct trusts' local implementation processes.
Verbatim wording from the response “BAPM is an advisory, not an executive body. We have made some relevant recommendations that can form the basis for local guidance. It is the responsibility of individual trusts to implement their own processes in line with national guidelines.” Source location Response from British Association of Perinatal Medicine
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Individual trusts are responsible for implementing local processes in line with national guidelines.
Verbatim wording from the response “BAPM is an advisory, not an executive body. We have made some relevant recommendations that can form the basis for local guidance. It is the responsibility of individual trusts to implement their own processes in line with national guidelines.” Source location Response from British Association of Perinatal Medicine
Open published response
12 Aug 2023 Baby Isabela Suciu · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 2 Failure to provide clear and consistent guidance when applying the Kaiser Permanente Score and NICE guidance View source Failure to use the Kaiser Permanente Score as part of an overall assessment of the patient View source
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AI-generated summary
Baby Isabela Suciu · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Baby Isabela Suciu was born in hospital and later suffered a cardiac arrest at home after feeding; she did not regain consciousness and died in hospital. Concerns included the failure to escalate low temperatures for paediatric review or start antibiotics, amid conflicting Kaiser Permanente and NICE guidance. The report identified a continuing risk of confusion and avoidable delay in other neonatal units, although the omission was not shown to have caused Isabela’s death.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Association of Perinatal Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to provide clear and consistent guidance when applying the Kaiser Permanente Score and NICE guidance
Wider context from the report “If the Newborn Early Warning Trigger and Track score had been followed the hypothermia would have triggered escalation by the midwife to paediatricians at 02.00 when the temperature was 36.3. Paediatrician ████████, advised that the KP score would not alter then, but at 06.20, the temperature of 36.2 should have triggered starting antibiotics. There was agreement amongst experts that antibiotics should have been started at 06.20 on 3rd of November. It is accepted by the doctors and Trust that this should have happened and did not because of conflict between the Kaiser Permanente Score and the NICE guidance. Whilst this omission was not shown to have caused Isabela’s death, it creates a possible risk for other hospitals using the KP scale.
Expert microbiologist ███████████ informed the court that it was not that the KP scale was inferior to NICE recommendations, but rather that there is a risk as the threshold for antibiotics is different, that doctors will think the KP score is gospel and not look at the patient as a whole and therefore miss clinical signs which should trigger starting antibiotics.
████████████████, consultant neonatology expert opined that the evidence for the use of KP pathway was thin, and it was better to follow NICE guidance as KP should only be used as part of an overall assessment. Expert neonatologist █████████████ agreed saying that the use of two guidelines was confusing .
████████ expert opinion was that there was a risk of deaths in other neonatal units and that the expert was not sure how well known the differences and apparent conflict in applying the guidelines was known. The Trust have taken a number of steps to address the risk, but there appears to remain the opportunity for confusion as the revised Newborn Early Warning Trigger and Track score indicates a different response from KP, when late onset symptoms occur after an asymptomatic period, creating a risk of avoidable delay .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Association of Perinatal Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure to use the Kaiser Permanente Score as part of an overall assessment of the patient
Wider context from the report “If the Newborn Early Warning Trigger and Track score had been followed the hypothermia would have triggered escalation by the midwife to paediatricians at 02.00 when the temperature was 36.3. Paediatrician ████████, advised that the KP score would not alter then, but at 06.20, the temperature of 36.2 should have triggered starting antibiotics. There was agreement amongst experts that antibiotics should have been started at 06.20 on 3rd of November. It is accepted by the doctors and Trust that this should have happened and did not because of conflict between the Kaiser Permanente Score and the NICE guidance. Whilst this omission was not shown to have caused Isabela’s death, it creates a possible risk for other hospitals using the KP scale.
Expert microbiologist ███████████ informed the court that it was not that the KP scale was inferior to NICE recommendations, but rather that there is a risk as the threshold for antibiotics is different, that doctors will think the KP score is gospel and not look at the patient as a whole and therefore miss clinical signs which should trigger starting antibiotics.
████████████████, consultant neonatology expert opined that the evidence for the use of KP pathway was thin, and it was better to follow NICE guidance as KP should only be used as part of an overall assessment . Expert neonatologist █████████████ agreed saying that the use of two guidelines was confusing.
████████ expert opinion was that there was a risk of deaths in other neonatal units and that the expert was not sure how well known the differences and apparent conflict in applying the guidelines was known. The Trust have taken a number of steps to address the risk, but there appears to remain the opportunity for confusion as the revised Newborn Early Warning Trigger and Track score indicates a different response from KP, when late onset symptoms occur after an asymptomatic period, creating a risk of avoidable delay.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue a safety notice reminding members about appropriate use of the neonatal sepsis and NEWTT2 tools.
Verbatim wording from the response “While the two tools mentioned above are used to determine which babies need additional observations, the NEWTT2 chart can then be used to track the observations and provides recommendations on escalation where necessary. We do have material on our website to support the use of the NEWTT2 chart and we will add a section to our frequently asked questions to ensure that staff are clear on the difference between tools for determining which babies need additional observations and the NEWTT2 tool for tracking those observations. We will also use a safety notice to our members to remind them of appropriate use of each of these tools.” Source location Response from Royal College of Paediatrics and Child Health
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add frequently asked questions clarifying the distinction between tools for determining additional observations and NEWTT2 for tracking observations.
Verbatim wording from the response “While the two tools mentioned above are used to determine which babies need additional observations, the NEWTT2 chart can then be used to track the observations and provides recommendations on escalation where necessary. We do have material on our website to support the use of the NEWTT2 chart and we will add a section to our frequently asked questions to ensure that staff are clear on the difference between tools for determining which babies need additional observations and the NEWTT2 tool for tracking those observations. We will also use a safety notice to our members to remind them of appropriate use of each of these tools.” Source location Response from Royal College of Paediatrics and Child Health
Open published response
Concerns raised 1 Lack of national guidelines for monitoring and treating infants at risk of haemolytic disease of the newborn, including DCT-positive infants, after acute treatment and discharge View source
Responses linked to these concerns
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No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Lola Sheldrake, also known as Lola Clarke · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Lola Sheldrake died aged 13 days on 23 December 2019 from severe anaemia caused by haemolytic disease of the newborn, which developed untreated after her discharge from hospital. The report raised concern that there were no national guidelines for monitoring and treating infants at risk, particularly following acute treatment after birth or discharge.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Association of Perinatal Medicine; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidelines for monitoring and treating infants at risk of haemolytic disease of the newborn, including DCT-positive infants, after acute treatment and discharge
Wider context from the report “that there are no national guidelines in respect of the monitoring and treatment of infants at risk of haemolytic disease of the newborn/DCT positive infants and in particular no guidelines as to good practice following acute treatment immediately after birth and/or following discharge .
” Open source report
19 Nov 2020 Master Yo Li · Prevention of Future Deaths report Surrey
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Concerns raised 4 Lack of NHS Trust requirements for internal UVC policies and procedures to comply with BAPM guidance View source Lack of NICE guidance on the use of UVCs View source Lack of NHS Trust requirements for clinicians to be familiar with BAPM guidance View source Failure of BAPM guidance to identify a key risk factor for mal-positioned UVCs View source See 1 more concern
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AI-generated summary
Master Yo Li · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Yo Li was born extremely prematurely on 11 January 2019 and died on 15 January 2019 after an umbilical venous catheter was mal-positioned, resulting in total parenteral nutrition extravasation. Concerns included gaps in professional guidance about a risk factor for mal-positioned catheters, clinicians’ lack of familiarity with updated guidance, and the absence of NICE guidance or a requirement for NHS Trusts to follow the relevant guidance.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Association of Perinatal Medicine; that does not assign responsibility.
PFD Monitor interpretation Lack of NHS Trust requirements for internal UVC policies and procedures to comply with BAPM guidance
Wider context from the report “2. There is no NICE guidance on the use of UVCs and there is no requirement on NHS Trusts to ensure that their clinicians are familiar with the BAPM guidance or to ensure that their internal policies and procedures are in accordance with it . Consideration ought to be given by NHSI to introducing some NICE guidance to cover this issue.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Association of Perinatal Medicine; that does not assign responsibility.
PFD Monitor interpretation Lack of NICE guidance on the use of UVCs
Wider context from the report “2. There is no NICE guidance on the use of UVCs and there is no requirement on NHS Trusts to ensure that their clinicians are familiar with the BAPM guidance or to ensure that their internal policies and procedures are in accordance with it. Consideration ought to be given by NHSI to introducing some NICE guidance to cover this issue.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Association of Perinatal Medicine; that does not assign responsibility.
PFD Monitor interpretation Lack of NHS Trust requirements for clinicians to be familiar with BAPM guidance
Wider context from the report “2. There is no NICE guidance on the use of UVCs and there is no requirement on NHS Trusts to ensure that their clinicians are familiar with the BAPM guidance or to ensure that their internal policies and procedures are in accordance with it. Consideration ought to be given by NHSI to introducing some NICE guidance to cover this issue.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Association of Perinatal Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure of BAPM guidance to identify a key risk factor for mal-positioned UVCs
Wider context from the report “1. The BAPM guidance on ‘Use of Central Venous Catheters in Neonates – A Framework for Practice’ does not identify a key risk factor for a mal-positioned UVC . Consideration ought to be given by BAPM to updating the guidance to include reference to this risk factor.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish an evidence-based Framework for Practice on neonatal central venous catheter use to reduce complications and support early recognition of extravasation.
Verbatim wording from the response “Among BAPM’s resources are a series of Frameworks for Practice (FfPs) which, following review of the literature, are written by multi-professional, voluntary working groups and published on our website after national consultation. Our FfPs are therefore evidence-based, consensus documents: specifically they are not guidelines, but as you note, guidance. This makes them highly suitable to inform local guidelines and protocols appropriate for individual neonatal units and/or networks. BAPM FfPs are reviewed regularly and updated if new evidence has become available.” Source location 2020-0245-Response-from-BAPM-Redacted.pdf
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The suggested amendment requiring NHS Trusts to ensure clinician familiarity with the current BAPM Framework is unnecessary and cannot be guaranteed to prevent recurrence.
Verbatim wording from the response “While we agree wholeheartedly with your recommendation that there should be a requirement on NHS Trusts to ensure that their clinicians are familiar with the current BAPM FfP for the use of Central Venous Catheters in Neonates, with the greatest of respect we contend that the suggested amendment is unnecessary and could not be guaranteed to prevent a recurrence of the incident described which led to the sad death of Master Yo Li.” Source location 2020-0245-Response-from-BAPM-Redacted.pdf
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations