Recipient

Queen Mary's Hospital for Children

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First report 2 Mar 2016•Latest report 2 Mar 2016

Recipient record

Reports, concerns and published responses

Health and care · Healthcare site. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

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

Reports over time

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found
0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Queen Mary's Hospital for Children linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Inner South London

    AI-generated summary

    Christ Morrison · 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

    Christ Morrison was born at 24 weeks gestation in 2005 and developed chronic lung disease requiring a tracheostomy. On 10 September 2014, the tracheostomy tube was removed and could not be replaced; despite resuscitation and transfer to a specialist centre, he died on 17 October 2014. The principal concerns were the training required for staff changing children's tracheostomy tubes at home, the absence of medical presence, and the lack of provision for an emergency tracheostomy when replacement failed.

    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 Queen Mary's Hospital for Children; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ensure staff are skilled and equipped to perform an emergency tracheostomy after failed tube replacement

    Wider context from the report

    “It was not clear what level of training was necessary for the staff changing tracheostomy tubes of children at home. The mother was very concerned that this should be performed by a nurse without medical presence. It was also submitted at inquest that in the event of failure to replace a tube, the health care professional should be skilled and equipped to perform a new emergency tracheostomy. This was not the position in this case. Whilst processes for changing tubes has changed since this inquest, with two staff as a minimum now being required to be present, the court was informed that the Epsom and St Helier Paediatric Tracheostomy Policy complied with processes complied with other Trusts. But it makes clear that failure to reintubate requires emergency transfer to A&E rather than emergency tracheostomy and does not require a medical presence. ”
    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 Queen Mary's Hospital for Children; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of clarity about necessary training levels for staff changing children's tracheostomy tubes at home

    Wider context from the report

    “It was not clear what level of training was necessary for the staff changing tracheostomy tubes of children at home. The mother was very concerned that this should be performed by a nurse without medical presence. It was also submitted at inquest that in the event of failure to replace a tube, the health care professional should be skilled and equipped to perform a new emergency tracheostomy. This was not the position in this case. Whilst processes for changing tubes has changed since this inquest, with two staff as a minimum now being required to be present, the court was informed that the Epsom and St Helier Paediatric Tracheostomy Policy complied with processes complied with other Trusts. But it makes clear that failure to reintubate requires emergency transfer to A&E rather than emergency tracheostomy and does not require a medical presence. ”
    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 Queen Mary's Hospital for Children; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide medical presence during children's tracheostomy tube changes at home

    Wider context from the report

    “It was not clear what level of training was necessary for the staff changing tracheostomy tubes of children at home. The mother was very concerned that this should be performed by a nurse without medical presence. It was also submitted at inquest that in the event of failure to replace a tube, the health care professional should be skilled and equipped to perform a new emergency tracheostomy. This was not the position in this case. Whilst processes for changing tubes has changed since this inquest, with two staff as a minimum now being required to be present, the court was informed that the Epsom and St Helier Paediatric Tracheostomy Policy complied with processes complied with other Trusts. But it makes clear that failure to reintubate requires emergency transfer to A&E rather than emergency tracheostomy and does not require a medical presence. ”
    Open source report
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

0%
0%All other recipients 58%
0%100%

How actions were described at the time

This respondent
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

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