South West Midlands Newborn Network SENAT

Health and care · Health-system partnership

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First report 19 Sep 2013•Latest report 19 Sep 2013

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 South West Midlands Newborn Network SENAT linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Birmingham and Solihull

    AI-generated summary

    Caitlynn Bethany Jane Bennet and 2 others · 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

    The report concerns the deaths of Caitlynn Bethany Jane Bennet, Mohammed Gulam Mohinudeen and Alfie-Scott Harris. It raises concerns about cardiac tamponade as a complication of central lines used for parenteral nutrition, including whether neonatal staff recognise the risk and whether best practice is shared between units. In Alfie-Scott Harris’s case, the report identified failures in the placement of the long-line end, although these were not considered gross.

    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 South West Midlands Newborn Network SENAT; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of NNUs to share best practice for limiting cardiac tamponade risk

    Wider context from the report

    “(1) NNU staff are not aware that cardiac tamponade may not be such a rare complication of TPN feeding as is thought. (2) NNUs may not be sharing best practice to limit this complication. This is the second Report that I am sending out in relation to an issue about babies dying of cardiac tamponade as a complication of central lines being put in for parenteral nutrition. I have now heard the evidence in relation to the third death and I am sufficiently concerned to write a further report. For everybody’s information, the first report was sent to Sir David Nicholson, Chief Executive of the National Health Service and it must have been forwarded onto The Royal College of Obstetricians and Gynaecologists by The National Health Services. The response from the Royal College stated that this was not a matter for them but it is a matter for the Royal College of Paediatrics and Child Health. In the meantime, matters have overtaken that and I have heard the Inquest in relation to the third death. I had asked for a report from a Senior Consultant Neonatologist, ████████ who has written me a report indicating essentially, that she has no concern about links between the three cases and that it is a known complication. I am aware that this doctor has now retired. In the third case that I heard of Alfie-Scott Harris, I have found that there were failures in relation to the placement of the end of the long line that he had in, although I did not find these to be gross, and, despite ████████ report, at the very least, it seems to me, that it should not be assumed that this is a rare complication. I have heard that City Hospital have brought in new measures to reduce the incidence of any failures in the future, (for instance having a high resolution x-ray scanning equipment on the Neonatal Unit as well as in Radiology, so that the clinicians can look at the x-rays. I refer to my summing up which is attached to this document). I am concerned that each Unit may not be sharing best practice about what is being done to minimise any risk. I am very conscious that this is a complicated medical issue which I have heard in some detail but you, as a clinician, will no doubt be aware of significant medical research that assists with clinical decision making about care of these lines. However, from my point of view, the first Inquest I heard in relation to this type of death was one where I was told that this was a complication which was incredibly rare. I am also told in the last Inquest of Alfie-Scott Harris, that there have lessons that have been learned and that changes have been made. I am not assured that any changes that have been made in one unit, had not been at least considered in another unit in relation to the same facts. ”
    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 South West Midlands Newborn Network SENAT; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of awareness that cardiac tamponade is not a rare complication of TPN feeding

    Wider context from the report

    “(1) NNU staff are not aware that cardiac tamponade may not be such a rare complication of TPN feeding as is thought. (2) NNUs may not be sharing best practice to limit this complication. This is the second Report that I am sending out in relation to an issue about babies dying of cardiac tamponade as a complication of central lines being put in for parenteral nutrition. I have now heard the evidence in relation to the third death and I am sufficiently concerned to write a further report. For everybody’s information, the first report was sent to Sir David Nicholson, Chief Executive of the National Health Service and it must have been forwarded onto The Royal College of Obstetricians and Gynaecologists by The National Health Services. The response from the Royal College stated that this was not a matter for them but it is a matter for the Royal College of Paediatrics and Child Health. In the meantime, matters have overtaken that and I have heard the Inquest in relation to the third death. I had asked for a report from a Senior Consultant Neonatologist, ████████ who has written me a report indicating essentially, that she has no concern about links between the three cases and that it is a known complication. I am aware that this doctor has now retired. In the third case that I heard of Alfie-Scott Harris, I have found that there were failures in relation to the placement of the end of the long line that he had in, although I did not find these to be gross, and, despite ████████ report, at the very least, it seems to me, that it should not be assumed that this is a rare complication. I have heard that City Hospital have brought in new measures to reduce the incidence of any failures in the future, (for instance having a high resolution x-ray scanning equipment on the Neonatal Unit as well as in Radiology, so that the clinicians can look at the x-rays. I refer to my summing up which is attached to this document). I am concerned that each Unit may not be sharing best practice about what is being done to minimise any risk. I am very conscious that this is a complicated medical issue which I have heard in some detail but you, as a clinician, will no doubt be aware of significant medical research that assists with clinical decision making about care of these lines. However, from my point of view, the first Inquest I heard in relation to this type of death was one where I was told that this was a complication which was incredibly rare. I am also told in the last Inquest of Alfie-Scott Harris, that there have lessons that have been learned and that changes have been made. I am not assured that any changes that have been made in one unit, had not been at least considered in another unit in relation to the same facts. ”
    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