Michael Chahwanda · Prevention of Future Deaths report

I concluded the inquest into the death of Michael Chahwanda on 13th January 2021 and recorded that he died from:

1a Circulatory failure following out of hospital cardiac arrest
1b Cardiomyopathy associated with Vitamin D deficiency

The Deceased was born on 19th September 2018 and died at Royal Manchester Children’s Hospital on 16th December 2018. The cause of his death was associated with a severe deficiency in Vitamin D. The Deceased (and his mother) had increased skin pigmentation.

The Deceased’s mother was advised to take Vitamin D in the ante-natal period; however, she was not advised to take supplements in the post-natal period, even though she was at a higher risk of Vitamin D deficiency as a result of her increased skin pigmentation and that she was breast-feeding.

On 16th December 2018 the Deceased suffered a seizure at home and wad admitted to hospital. He had no respiratory or heart rate, and showed signs of hyperkalaemia and hypocalcaemia. He died at the hospital on the same day.

At the Inquest, held on 13th January 2021, I explored the national guidance on Vitamin D supplementation, together with the contents of ‘My Personal Child Health Record’ (commonly referred to as ‘The Red Book’). The latter makes no reference to Vitamin D supplementation advice being provided to mothers. The only reference to Vitamin D supplementation is an advert from a national charity, although this does not refer to specific advice.

Moreover, I explored the issue of provision of Vitamin D supplements to mothers, and the cost-effective of this. I heard evidence from a leading Consultant in Paediatric Bone Disease, who told me that the national guidance provides advice to mothers, whereas it should be a directive for mothers to take Vitamin D. In addition, the evidence from the Consultant was that it would be cost-effective for the National Health Service to provide Vitamin D supplements to mothers and breast-fed babies. The Consultant highlighted the fact that breastmilk does not contain Vitamin D as of crucial importance.

1. To The Royal College of Paediatrics and Child Health and Department of Health and Social Care and The National Institute for Health and Care Excellence: To consider an amendment to the Red Book to include specific advice for Vitamin D supplementation in the postnatal period to be given by the attending Health Visitor. Such advice would be consistent with national guidance.

2. To Department of Health and Social Care and The National Institute for Health and Care Excellence : To consider an amendment to the guidelines so that there is a directive for women (particularly those with an increased skin pigmentation and those who are breast-feeding) to take Vitamin D supplements. Also, to consider the provision of Vitamin D to women and babies who are at an increased risk of Vitamin D deficiency.