PFD report

Carter Isaac Jepson · Prevention of Future Deaths report

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Issued 21 May 2018•Manchester South

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear 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

Source document

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
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

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

    Stated by Department of Health and Social CareRedirects 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 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

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Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-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. 1

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

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 8 July 2018.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    The concern does not involve a risk of future death.

    Stated by Department of Health and Social CareDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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
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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