Naiya Diarra · Prevention of Future Deaths report

Naiya Diarra died on 25 June 2015, aged 9 months old, from dilated cardiomyopathy, arising from severe Vitamin D deficiency. An inquest into her death was heard on 30 October 2015, at which I recorded a narrative conclusion (see attached).

Naiya was not known to have developed the severe Vitamin D deficiency, from which she ultimately died. I heard evidence that vitamin supplementation was discussed with her mother and instituted through her mother taking additional dietary vitamins and later through use of additional formula feeding. However, it is clear that this was ultimately insufficient to prevent her death. Her siblings was known to be Vitamin D deficient and I saw evidence that health visitors had attended the family home regarding this and had given advice regarding sunlight exposure in particular. However, the significance of her sibling’s deficiency was not recognised by those treating Naiya and I concluded that there was missed opportunities to address this.

I heard evidence that NICE guidance exists regarding the identification and treatment of Vitamin D deficiency

(1) Multiple pieces of relevant information regarding ████████ current illness were contained in disparate record ‘silos’. It was difficult for clinicians to access this information and, as such, it was not available to the reviewing psychiatric team, in particular.

I am concerned that the previous focus on access to medical records, which was to occur through the NHS Programme for IT, has been lost and that the new focus on patient access to GP records will not address the risks posed by the current state of record sharing within the NHS.