PFD report

Jared William McDowall · Prevention of Future Deaths report

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Issued 27 Sep 2013•Avon

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
4

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
0

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

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Concerns raised4

  1. Lack of competency-assessed education on recognising an unwell baby for doctors and midwives
  2. Inadequate risk-based criteria and guidance for admission to the transitional area
  3. Lack of competency-assessed education on hypoglycaemia for doctors and midwives
    Part of recurring concern: Unsafe recognition and management of hypoglycaemia
Responses linked to these concerns

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

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

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 competency-assessed education on recognising an unwell baby for doctors and midwives

Wider context from the report

“During the inquest I heard evidence of a cut off weight for babies to go into a transitional area where they will receive more careful monitoring. Currently the guideline is babies weighing over 2.5kg do not need to go into this unit. ████████ a Consultant Neonatologist from the hospital gave evidence about this and indicated that there should be different weights for gestation and different guides for boys and girls. He also said that the presentation of the evidence would be better if it was graphically done and that by referring to a graph it would give a better understanding of a baby being at risk to the staff. In addition ████████ said that there was a need to synthesize joint working with doctors and midwives. That there should be educational packages for hypoglycaemia and for recognising an unwell baby for both doctors and midwives with a measurement of competency. ”

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

Inadequate risk-based criteria and guidance for admission to the transitional area

Wider context from the report

“During the inquest I heard evidence of a cut off weight for babies to go into a transitional area where they will receive more careful monitoring. Currently the guideline is babies weighing over 2.5kg do not need to go into this unit. ████████ a Consultant Neonatologist from the hospital gave evidence about this and indicated that there should be different weights for gestation and different guides for boys and girls. He also said that the presentation of the evidence would be better if it was graphically done and that by referring to a graph it would give a better understanding of a baby being at risk to the staff. In addition ████████ said that there was a need to synthesize joint working with doctors and midwives. That there should be educational packages for hypoglycaemia and for recognising an unwell baby for both doctors and midwives with a measurement of competency. ”

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

Lack of competency-assessed education on hypoglycaemia for doctors and midwives

Wider context from the report

“During the inquest I heard evidence of a cut off weight for babies to go into a transitional area where they will receive more careful monitoring. Currently the guideline is babies weighing over 2.5kg do not need to go into this unit. ████████ a Consultant Neonatologist from the hospital gave evidence about this and indicated that there should be different weights for gestation and different guides for boys and girls. He also said that the presentation of the evidence would be better if it was graphically done and that by referring to a graph it would give a better understanding of a baby being at risk to the staff. In addition ████████ said that there was a need to synthesize joint working with doctors and midwives. That there should be educational packages for hypoglycaemia and for recognising an unwell baby for both doctors and midwives with a measurement of competency. ”

Is this part of a recurring concern?

Yes — Unsafe recognition and management of hypoglycaemia.

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 to establish effective joint working between doctors and midwives

Wider context from the report

“During the inquest I heard evidence of a cut off weight for babies to go into a transitional area where they will receive more careful monitoring. Currently the guideline is babies weighing over 2.5kg do not need to go into this unit. ████████ a Consultant Neonatologist from the hospital gave evidence about this and indicated that there should be different weights for gestation and different guides for boys and girls. He also said that the presentation of the evidence would be better if it was graphically done and that by referring to a graph it would give a better understanding of a baby being at risk to the staff. In addition ████████ said that there was a need to synthesize joint working with doctors and midwives. That there should be educational packages for hypoglycaemia and for recognising an unwell baby for both doctors and midwives with a measurement of competency. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report
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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