PFD report

Maya ZAB · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 16 Sep 2021•West Yorkshire (Western)

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.

View original report
Concerns
4

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
11

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

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

Concerns raised4

  1. Inability of some households to purchase balanced, good-quality nutrition for children
  2. Failure of other professionals, friends and family to report concerns about children’s health
  3. Insufficient one-to-one consultations for health professionals to identify signs of anaemia in children
    Part of recurring concern: Unreliable recognition and assessment of anaemia
Responses linked to these concerns

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

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.6

  1. Action

    Work with NHS Business Services Authority to raise awareness and uptake of the Healthy Start programme.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 23 September 2021.
  2. Action

    Repatriate redeployed public health nurses to health visiting services.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 23 September 2021.
  3. Action

    Transfer Healthy Start support from paper vouchers to digital cards.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 23 September 2021.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    National and regional data do not show a significant increase in malnutrition or iron-deficiency anaemia.

    Stated by NHS EnglandDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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

Inability of some households to purchase balanced, good-quality nutrition for children

Wider context from the report

“During the evidence it became clear that in the Yorkshire & Humber region there has been an increased incidence of severe nutritional anaemia in 2020 in a paediatric setting, resulting in 2 deaths, Maya’s death being one of the two. The witness had not seen any deaths previously in her career. The witness had consulted 9 colleagues over the data. They surmise that a number of factors arising indirectly from the pandemic may explain the findings: • The “stay at home” message resulted in less 1 to 1 consultations, so health professionals were not able to spot the signs of anaemia • Limitation of social contact meant other professionals and friends and family were not able to report concerns about a child’s health • Widening of socio-economic inequalities (including unemployment and reduced household earning capacities) means that certain members of society are not able to purchase a balanced,good quality nutrition for their children I accept that these are not factors that have been scientifically tested, but nevertheless the increase in the incidents of anaemia and the deaths that are arising are a matter of concern ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

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

Failure of other professionals, friends and family to report concerns about children’s health

Wider context from the report

“During the evidence it became clear that in the Yorkshire & Humber region there has been an increased incidence of severe nutritional anaemia in 2020 in a paediatric setting, resulting in 2 deaths, Maya’s death being one of the two. The witness had not seen any deaths previously in her career. The witness had consulted 9 colleagues over the data. They surmise that a number of factors arising indirectly from the pandemic may explain the findings: • The “stay at home” message resulted in less 1 to 1 consultations, so health professionals were not able to spot the signs of anaemia • Limitation of social contact meant other professionals and friends and family were not able to report concerns about a child’s health • Widening of socio-economic inequalities (including unemployment and reduced household earning capacities) means that certain members of society are not able to purchase a balanced,good quality nutrition for their children I accept that these are not factors that have been scientifically tested, but nevertheless the increase in the incidents of anaemia and the deaths that are arising are a matter of concern ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

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

Insufficient one-to-one consultations for health professionals to identify signs of anaemia in children

Wider context from the report

“During the evidence it became clear that in the Yorkshire & Humber region there has been an increased incidence of severe nutritional anaemia in 2020 in a paediatric setting, resulting in 2 deaths, Maya’s death being one of the two. The witness had not seen any deaths previously in her career. The witness had consulted 9 colleagues over the data. They surmise that a number of factors arising indirectly from the pandemic may explain the findings: • The “stay at home” message resulted in less 1 to 1 consultations, so health professionals were not able to spot the signs of anaemia • Limitation of social contact meant other professionals and friends and family were not able to report concerns about a child’s health • Widening of socio-economic inequalities (including unemployment and reduced household earning capacities) means that certain members of society are not able to purchase a balanced,good quality nutrition for their children I accept that these are not factors that have been scientifically tested, but nevertheless the increase in the incidents of anaemia and the deaths that are arising are a matter of concern ”

Is this part of a recurring concern?

Yes — Unreliable recognition and assessment of anaemia.

Open source report

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

Increased incidence of severe nutritional anaemia and associated deaths in children

Wider context from the report

“During the evidence it became clear that in the Yorkshire & Humber region there has been an increased incidence of severe nutritional anaemia in 2020 in a paediatric setting, resulting in 2 deaths, Maya’s death being one of the two. The witness had not seen any deaths previously in her career. The witness had consulted 9 colleagues over the data. They surmise that a number of factors arising indirectly from the pandemic may explain the findings: • The “stay at home” message resulted in less 1 to 1 consultations, so health professionals were not able to spot the signs of anaemia • Limitation of social contact meant other professionals and friends and family were not able to report concerns about a child’s health • Widening of socio-economic inequalities (including unemployment and reduced household earning capacities) means that certain members of society are not able to purchase a balanced,good quality nutrition for their children I accept that these are not factors that have been scientifically tested, but nevertheless the increase in the incidents of anaemia and the deaths that are arising are a matter of concern ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

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

Work with NHS Business Services Authority to raise awareness and uptake of the Healthy Start programme.

Verbatim wording from the response

“It was agreed that working with the NHS Business Services Authority (NHS BSA) to raise the profile and uptake of the Healthy Start programme would benefit both”

Source location

2021-0316-Response-from-NHS-England_Published
Page 2 · response
Published 23 September 2021

Open published response

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

Repatriate redeployed public health nurses to health visiting services.

Verbatim wording from the response

“We recognise the impact the pandemic has had on the delivery of health visiting services. With the onset of COVID-19, some public health nurses were redeployed, however I can confirm that they were all repatriated by the end of July 2020.”

Source location

2021-0316-Response-from-NHS-England_Published
Page 2 · response
Published 23 September 2021

Open published response

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

Transfer Healthy Start support from paper vouchers to digital cards.

Verbatim wording from the response

“The Healthy start programme helps parents with children under the age of 4 and pregnant women to buy healthy food and milk. The scheme is in the process of transferring from paper vouchers to a digital cards, this will support quicker application decisions, allow use of the cards anywhere that accepts Mastercard®, automatic top up every 4 weeks, allows partial use of allowance (not previously available) and is discreet payment option.”

Source location

2021-0316-Response-from-NHS-England_Published
Page 3 · response
Published 23 September 2021

Open published response

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

Advise services not to redeploy professionals supporting children and families, and support provision to vulnerable families.

Verbatim wording from the response

“In response to Winter Planning in 2020, Public Health England and NHSEI Chief Nurses, together with the Local Government Association, wrote to Directors of Nursing across the country to advise that professionals supporting children and families, such as health visitors, school nurses, designated safeguarding officers and nurses supporting children with special educational needs, should not be redeployed to other services and should be supported to provide services through pregnancy, early years and to the most vulnerable families. (Joint letter on Winter Planning: Support to Children and Families, 7 October 2020 | Local Government Association.)”

Source location

2021-0316-Response-from-NHS-England_Published
Page 2 · response
Published 23 September 2021

Open published response

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 an updated health visiting and school nursing delivery model with commissioning guidance.

Verbatim wording from the response

“Further an updated health visiting and school nurse service delivery model, together with commissioning guidance, was also published in March 2021. (Health visiting and school nursing service delivery model - GOV.UK (www.gov.uk).)”

Source location

2021-0316-Response-from-NHS-England_Published
Page 2 · response
Published 23 September 2021

Open published response

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

Restore NHS services following pandemic disruption.

Verbatim wording from the response

“Whilst contact with the NHS was reduced during the pandemic, there was also a clear narrative that the NHS remains open for patients who need care, and this remains the message. NHSEI is working hard to restore services across the country.”

Source location

2021-0316-Response-from-NHS-England_Published
Page 2 · response
Published 23 September 2021

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

National and regional data do not show a significant increase in malnutrition or iron-deficiency anaemia.

Verbatim wording from the response

“National data sets do not show any national or regional increases in malnutrition. The data used was the secondary user service (SUS) data in the NHS England national clinical data repository (NCDR), the equivalent data is available on the NHS Digital website, where the data is available as a provisional dataset.”

Source location

2021-0316-Response-from-NHS-England_Published
Page 3 · response
Published 23 September 2021

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

Available data does not show a significant national or regional increase in iron deficiency anaemia diagnoses.

Verbatim wording from the response

“NHSEI advises that data relating to diagnoses of iron deficiency anaemia¹ does not show any significant increase nationally or regionally. The numbers regionally, by month, are generally quite low and can vary considerably month by month. However, the overall trend shows no significant increase. I hope this information is helpful.”

Source location

2021-0316-Response-from-Department-of-Health-Social-Care_Published
Page 1 · response
Published 23 September 2021

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

Existing healthy-diet promotion efforts are considered sufficient; no policy specifically targeting nutritional anaemia will be introduced.

Verbatim wording from the response

“The Government does not have any plans to introduce policies to specifically target nutritional anaemia in children. However, the Government’s efforts to promote a healthy balanced diet for children contribute to this goal by encouraging the intake of food rich in nutrients essential to preventing anaemia, such as iron.”

Source location

2021-0316-Response-from-Department-of-Health-Social-Care_Published
Page 3 · response
Published 23 September 2021

Open published response

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.5

  1. 1

    Make the digital-service evidence available to commissioners, providers and professionals for future service design.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 23 September 2021.
  2. 2

    Identify evidence on digital technology’s impact on children’s public health service delivery with Keele University academics.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 23 September 2021.
  3. 3

    Integrate care nationally with particular focus on reducing inequalities and supporting vulnerable children, young people and families.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 23 September 2021.
  4. 4

    Make the identified evidence on digitally delivered services available to local commissioners, providers and professionals to inform future service design.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 23 September 2021.
  5. 5

    Work with Keele University academics to identify evidence on the impact and quality of digitally delivered public health services for children and families.

    Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 23 September 2021.

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

Make the digital-service evidence available to commissioners, providers and professionals for future service design.

Verbatim wording from the response

“I am able to confirm that DHSC are currently working with academics from Keele University to identify available evidence on the impact of digital technologies on public health service delivery to children, young people and families. The specific objective of this work is to identify the quality of digitally delivered services in relation to quality of engagement and development of therapeutic relationships. This evidence will then be made available to local service commissioners, their providers and professionals to inform future service design.”

Source location

2021-0316-Response-from-NHS-England_Published
Page 2 · response
Published 23 September 2021

Open published response

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

Identify evidence on digital technology’s impact on children’s public health service delivery with Keele University academics.

Verbatim wording from the response

“I am able to confirm that DHSC are currently working with academics from Keele University to identify available evidence on the impact of digital technologies on public health service delivery to children, young people and families. The specific objective of this work is to identify the quality of digitally delivered services in relation to quality of engagement and development of therapeutic relationships. This evidence will then be made available to local service commissioners, their providers and professionals to inform future service design.”

Source location

2021-0316-Response-from-NHS-England_Published
Page 2 · response
Published 23 September 2021

Open published response

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

Integrate care nationally with particular focus on reducing inequalities and supporting vulnerable children, young people and families.

Verbatim wording from the response

“In terms of your concern regarding the widening of socio-economic inequalities, I can confirm that NHSEI are working to integrate care across the country with a particular focus on addressing inequalities and supporting children, young people and their families who may be vulnerable.”

Source location

2021-0316-Response-from-NHS-England_Published
Page 2 · response
Published 23 September 2021

Open published response

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

Make the identified evidence on digitally delivered services available to local commissioners, providers and professionals to inform future service design.

Verbatim wording from the response

“We are working with academics from Keele University to identify currently available evidence on the impact of digital technologies on public health service delivery to children, young people and families. The specific objective of this work is to identify the quality of digitally delivered services in relation to quality of engagement and development of therapeutic relationships.”

Source location

2021-0316-Response-from-Department-of-Health-Social-Care_Published
Page 2 · response
Published 23 September 2021

Open published response

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

Work with Keele University academics to identify evidence on the impact and quality of digitally delivered public health services for children and families.

Verbatim wording from the response

“We are working with academics from Keele University to identify currently available evidence on the impact of digital technologies on public health service delivery to children, young people and families. The specific objective of this work is to identify the quality of digitally delivered services in relation to quality of engagement and development of therapeutic relationships.”

Source location

2021-0316-Response-from-Department-of-Health-Social-Care_Published
Page 2 · response
Published 23 September 2021

Open published response
Back to top

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