Carter Isaac Jepson · Prevention of Future Deaths report

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Issued 21 May 2018•Manchester South

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
1

Described in responses

Recipients and published responses

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised1

  1. Lack of a process or protocol for prescribing medication to stop lactation after unexpected child loss

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. Department of Health and Social Care

    Publish new statutory guidance for child death reviews in England to promote consistent, high-standard local reviews and capture learning nationally.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Department of Health and Social Care

    The concern does not involve a risk of future death.

    Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
  2. Department of Health and Social Care

    NHS trusts are responsible for comprehensive bereavement guidance covering lactation-suppression information and support.

    Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of a process or protocol for prescribing medication to stop lactation after unexpected child loss

Wider context from the report

“The inquest heard that Carter had been breastfed. Following his death, his mother was significantly impacted, psychologically, by his loss. The inquest heard that this was exacerbated because there was no process/protocol in place to prescribe her medication to stop lactation. As a result she continued to lactate whilst dealing with her loss. The inquest heard that the SUDC paediatricians dealing with the case had identified this as a national issue relating to breastfeeding mothers dealing with the trauma of the unexpected loss of their child. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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 new statutory guidance for child death reviews in England to promote consistent, high-standard local reviews and capture learning nationally.

Verbatim wording from the response

“We will shortly be publishing new statutory guidance on the process for child death reviews in England to ensure a uniform, high-standard of reviews locally and that each local area is able to capture learning that may be applicable at the national level.”

Source location

2018-0154-Response-by-Department-of-Health
Page 3 · response
Published 8 July 2018

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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 concern does not involve a risk of future death.

Verbatim wording from the response

“Your Report raises a matter of concern that, while not involving a risk of future death, can clearly be a very distressing physical experience after the death of a baby, and it is concerning to hear that you heard evidence at inquest that a lack of support might be a national issue.”

Source location

2018-0154-Response-by-Department-of-Health
Page 1 · response
Published 8 July 2018

Open published response

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

NHS trusts are responsible for comprehensive bereavement guidance covering lactation-suppression information and support.

Verbatim wording from the response

“It is therefore for NHS trusts to ensure they have in place comprehensive, compassionate guidance for bereavement care which includes the provision of information and support on lactation suppression, based on best practice and evidence.”

Source location

2018-0154-Response-by-Department-of-Health
Page 3 · response
Published 8 July 2018

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026