PFD report

Nathan James Healer · Prevention of Future Deaths report

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Issued 25 Jul 2014•Sunderland

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
2

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

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

Concerns raised2

  1. Failure to provide timely blood glucose testing for newborns
    Part of recurring concern: Failure to provide timely clinically required blood testsPart of recurring concern: Failure to reliably measure and monitor blood glucose levels
  2. Lack of finalized and current guidance on newborn blood glucose testing
    Part of recurring concern: Failure to reliably measure and monitor blood glucose levels
Responses linked to these concerns

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

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    Further questions about the guidance review should be directed to NICE, an independent body.

    Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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 provide timely blood glucose testing for newborns

Wider context from the report

“I was made aware of :- a) the 2008 NICE Clinical Guidance 63 “Diabetes in Pregnancy” which in essence recommended a pre 2nd Feed Blood Glucose test at between 2-4 hours; b) the hospital Guidance for “Hypothermia in the newborn Infant” 2014; c) the hospital Guidance for “Prevention, detection and management of hypoglycaemia in the newborn 2012 (Blood glucose test at around 4 hours). Although the severity of Nathans’s condition was not appreciated and he was not given the opportunity of a more timely blood glucose test I heard evidence that although new guidance from NICE is in contemplation it has not yet been finalised. If that is the case then it would be helpful to know what stage this is at and whether any steps can be taken to expedite it’s production. If no new guidance is in contemplation then it may be an opportune moment to revisit the guidance in any event. ”

Is this part of a recurring concern?

Yes — Failure to provide timely clinically required blood tests; Failure to reliably measure and monitor blood glucose levels.

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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 finalized and current guidance on newborn blood glucose testing

Wider context from the report

“I was made aware of :- a) the 2008 NICE Clinical Guidance 63 “Diabetes in Pregnancy” which in essence recommended a pre 2nd Feed Blood Glucose test at between 2-4 hours; b) the hospital Guidance for “Hypothermia in the newborn Infant” 2014; c) the hospital Guidance for “Prevention, detection and management of hypoglycaemia in the newborn 2012 (Blood glucose test at around 4 hours). Although the severity of Nathans’s condition was not appreciated and he was not given the opportunity of a more timely blood glucose test I heard evidence that although new guidance from NICE is in contemplation it has not yet been finalised. If that is the case then it would be helpful to know what stage this is at and whether any steps can be taken to expedite it’s production. If no new guidance is in contemplation then it may be an opportune moment to revisit the guidance in any event. ”

Is this part of a recurring concern?

Yes — Failure to reliably measure and monitor blood glucose levels.

Open source report

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

Further questions about the guidance review should be directed to NICE, an independent body.

Verbatim wording from the response

“Given the imminence of the new guidance, advice from Departmental policy officials is that there is no scope for this process to be expedited. However, as NICE is an independent body, I advise you contact it directly with any further questions you may have about the review of this guidance.”

Source location

2014-0343-Response-by-Department-of-Health
Page 2 · response
Published 25 July 2014

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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

The imminent NICE guidance review cannot be expedited.

Verbatim wording from the response

“Given the imminence of the new guidance, advice from Departmental policy officials is that there is no scope for this process to be expedited. However, as NICE is an independent body, I advise you contact it directly with any further questions you may have about the review of this guidance.”

Source location

2014-0343-Response-by-Department-of-Health
Page 2 · response
Published 25 July 2014

Open published response
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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