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Investigation and inquest
On 9/12/25, I concluded the inquest into the death of Izzah Fatima Ali who died on 7/9/24 at the age of 9 months.
I recorded the cause of death as:
1a Acute on chronic decompensated heart failure
1b Cardiomyopathy
1c Iron deficiency anaemia (treated with a blood transfusion)
I recorded a conclusion that Izzah died from complications caused by her treatment for profound iron-deficiency anaemia in turn due to her consumption of cow’s milk. A copy of my full judgment is available upon request.
Circumstances of the death
Izzah was a nine-month-old female infant who had been born fit and well. Both of her parents came from Pakistan and her mother had only been in England for a couple of months before her daughter was born. She did not speak English.
An interpreter was not used at ante-natal interactions contrary to guidance. A guide to feeding your baby was produced in English only and it did not set out that providing cow’s milk to an infant under the age of one was contra-indicated as it ran the risk of causing iron-deficiency anaemia. A UNICEF guide that was available in Urdu and which explained this was not provided.
There were two health visitor attendances again without an interpreter present. At the time of the second attendance, Izzah was still breast-fed only.
Unaware of the risks of using cow’s milk, Izzah’s parents provided this to their daughter believing it would be beneficial to her.
There were multiple interactions with a wide variety of different healthcare professionals when it was noted Izzah was being breast and bottle fed. No inquiry was made to check that bottle fed meant formula fed or otherwise to establish what was in the bottles being given to Izzah. It was not identified that she was receiving cow’s milk until her last admission to hospital.
On 6 August 2024, Izzah was seen in a Minor Injuries Unit and then referred to paediatric colleagues in Royal Cornwall Hospital. At that time it is more likely than not that she had developed anaemia and this was the cause of her pallor and distended abdomen. A urine dipstick confirmed a urinary tract infection and antibiotics were prescribed. The anaemia was not diagnosed.
On 6 September 2024, Izzah was re-admitted into Royal Cornwall Hospital. It was established that she was profoundly anaemic. She needed to be treated by transfusion and this was undertaken. Izzah had a collapse and suffered cardiac arrests. She could not be resuscitated and was verified deceased on 7 September 2024.
Coroner’s concerns
1) A theme that emerged during the evidence was the repeated reference to Izzah being ‘bottle-fed’ without further inquiry. In this country, bottle-fed infers ‘formula-fed’ but it is a presumption and in this case it was a wrongly assumed presumption. As one witness observed: ‘bottle-fed’ does not explain what was in the bottle. It could be a formula preparation, equally, it could be expressed breast milk. In this case, it was cow’s milk but until Izzah’s last admission into hospital no healthcare professional established that crucial fact.
That reflects a failure to recognise that ‘bottle-fed’ is an incomplete description and requires an additional question of what is in the bottle.
It also reflects a lack of appreciation around different cultural practices: while it may be assumed that cow’s milk would not be given to an infant under one in this country, it does not automatically follow that the same is true in other countries, for example, Pakistan. There was, in my judgment, an element of assumption made here which could alternatively be described as a lack of professional curiosity.
- A second concern that emerged was that during both ante- and post-natal visits to a woman who did not speak English, no interpreter was involved, contrary to guidance.
Information checked against the published report and official responses