Government Commercial Agency

Central government · Executive agency

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First report 26 Nov 2025•Latest report 26 Nov 2025

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

Statements from Government Commercial Agency linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Addressed to Crown Commercial Service, now represented here by Government Commercial Agency.

    South London

    AI-generated summary

    Evie Rae Le Masurier-O'Sullivan · 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

    Evie became unwell with respiratory distress on the post-natal ward less than a day after birth and died after deteriorating with sepsis-related complications. The report identified concerns that staff did not elicit or provide an opportunity for her parents to share concerns about her crying and breathing, contributing to a lack of neonatal assessment and escalation, and that antibiotics were delayed. It also identified a training gap for temporary staff in eliciting parental concerns, creating a risk of future deaths unless action is taken.

    Read the report on judiciary.uk

    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 Government Commercial Agency; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to elicit and provide an opportunity for sharing parental concerns about a baby’s wellbeing during postnatal contacts

    Wider context from the report

    “4. On attending the mother’s bedside, the midwife or midwife assistant (also known as maternity assistants or midwifery assistants) should ensure that there are no parental concerns about the baby. Although there are different ways in which this important objective can be achieved, the midwife or midwife assistant should ensure that they ask questions in a way that ensures that the family had an “open space” to share their concerns. In other words, it is important that: (i) the questions asked by the midwife or midwife assistant are asked in a way that can elicit any such concerns; (ii) they afford the parents an adequate opportunity for those concerns to be shared; and (iii) their attitude to, and interactions with, the parents creates an environment in which parents feel able to share concerns. In Evie’s case, I concluded that: although Evie's mother was seen by a member of the midwifery team at postnatal contacts at around 00:30 and by a midwife at around 02:30, they did not elicit concerns Evie's parents had about Evie's crying and breathing, and nor did they afford an opportunity for these concerns to be shared; and this led to an absence of neonatal assessments being carried out and absence of escalation to the hospital's neonatal team, which contributed to the death. ”
    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 Government Commercial Agency; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of training for temporary staff in eliciting parental concerns about a baby’s wellbeing during postnatal contacts

    Wider context from the report

    “However, I also received evidence that: (i) all temporary staffing supplied at Croydon University Hospital including midwives is provided by “On-Framework” suppliers under framework RM6281 (RM6281 is a framework agreement managed under the NHS Workforce Alliance for the procurement of clinical and healthcare staffing across the UK); and (ii) most NHS Trusts, including Croydon Health Services NHS Trust, do not provide in-house training to their agency staff as they are not provided with funding for them to be trained. This means that there is a training gap, in that temporary staff provided by “On-Framework” suppliers under framework RM6281, including those working at Croydon University Hospital, will not receive the additional training identified above in relation to eliciting parental concerns about a baby’s wellbeing at postnatal contacts. In my opinion, this training gap gives rise to a risk that future deaths could occur unless action is taken. ”
    Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026