Chapter 28. The current position

The Countess

In 2025, the Countess opened an impressive combined facility for women and children.¹ It includes the current neonatal unit, opened in 2021, which occupies a larger, modern space where family integrated care is facilitated. Parents are encouraged to attend ward rounds, and babies’ cots are next to their mothers.
The Countess has a Safeguarding and Promoting the Welfare of Children Policy dated 1 September 2022, in which the Trust commits to ensuring that all staff have access to expert advice, support and safeguarding supervision and training in relation to safeguarding children. The policy specifically addresses the possibility that a member of staff may have harmed a child, committed a criminal offence or displayed behaviours which may indicate that they are not suited to work with children. In such circumstances, the Associate Director of Safeguarding is directed to ensure that a referral is made to the LADO.² This is a welcome and important improvement.

Intercollegiate document

In their submissions, the RCPCH refer to a framework for all healthcare staff published in November 2025: ‘Intercollegiate document (2025) Safeguarding children and young people & children and young people in care: Competencies for health care staff’.³ The document brings together and updates two previous documents (Safeguarding Children and Young People: Roles and competencies for healthcare staff (2019) and Looked After Children: Roles and competencies of healthcare staff (2020)).⁴ It sets out a system of five different levels, with an additional level for senior managers and executives. Level 3, the level for healthcare professionals and staff who deliver a clinical service to children, makes a passing reference under the heading ‘Underlying knowledge’ to the LADO process.⁵ The streamlining of guidance is welcome, but the resulting document is neither clear nor concise.
The competencies, resources and references do not include mention of learning from previous inquiries or reference to the possibility that healthcare professionals may be responsible for deliberate harm to a child.
Appendix 5 provides a ‘comprehensive’ list of safeguarding and children and young people in care legislation, and statutory and non-statutory guidance.⁶ There are 13 links to separate documents for England alone.
I am sorry to say that, whilst the effort taken to produce this guidance is no doubt significant, the effort and time required to read it are too great when something needs to be dealt with immediately. What is needed is clear, focused guidance. The guidance produced for use in schools, as well as providing background and context, is clearer and more direct about what to do in a variety of situations, including when a member of staff has a safeguarding concern or an allegation about another staff member.⁷
I acknowledge that, whilst it is useful for everyone working in healthcare to have an understanding of the importance of safeguarding and the reasons for it, including an understanding of the context in which children live, such information should be provided by way of guidance. What is at least as important is that there be a short, clear document setting out what to do when there are suspicions that a member of staff may be harming children.
In a world bristling with frameworks and competencies, short, clear documents are essential.

Memorandum of Understanding

On 17 December 2024, guidance was issued on investigating healthcare incidents where suspected criminal activity may have contributed to death or serious life-changing harm. This Memorandum of Understanding between regulatory, investigatory and prosecutorial bodies sets out at paragraph 2.1 that it “has been produced to help deliver early, co-ordinated and effective action following incidents where there is reasonable suspicion that a patient/service user’s death or serious life-changing harm occurred as a result of an incident where there is suspected criminal activity in the course of healthcare delivery”.⁸

Neonatal Mortality Governance framework

BAPM published its Neonatal Mortality Governance framework in February 2026.⁹ Dr Eleri Adams, BAPM President and NHS England Getting It Right First Time (GIRFT) Clinical Lead for Neonatology, led the development of the guidance with a working group that includes Dr Ngozi Edi-Osagie, NHS England National Clinical Director for Neonatology, who has also provided a statement to the Inquiry.¹⁰
The framework provides detailed operational guidance on mortality governance in neonatal services and is intended to complement existing national and statutory guidance across the UK. It is aimed primarily at perinatal healthcare professionals but may also be relevant to coroners and medical examiners. It sets out expectations for: governance and leadership of neonatal mortality processes; investigation and review of deaths; engagement with coronial and statutory processes; and support for families and staff, including bereavement care. It does not include a mechanism for ensuring the guidance is complied with nor the consequences of failure to do so. I address these issues later in this chapter.

Post-mortem examinations

The Neonatal Mortality Governance framework makes clear that all parents should be offered a post-mortem examination following a neonatal death, recognising its importance for establishing cause of death, supporting learning, and providing understanding and closure for families. In coronial cases, a post-mortem examination may be mandated.
There are only 43 paediatric pathologists in England.¹¹ Without a successful programme to train more, this cannot be achieved (see paragraphs 28.24 to 28.31). I acknowledge the commitment that has already been made. I recommend a clear timetable (see paragraph 28.31).
The framework links post-mortems to:
- Child Death Review meetings
- escalation to coronial authorities where appropriate
- thematic review and system-wide learning, including identification of clusters, trends or unexpected findings.¹²

Sudden unexpected neonatal deaths (SUDIC, SUDI, PRUDiC, SUPC)

This section of the framework points out that, whilst such deaths are uncommon in neonatal units and post-natal wards, they require prompt and structured responses.
BAPM states that deaths meeting the criteria for sudden unexpected death (including SUDIC, SUDI, Procedural Response to Unexpected Death in Childhood (PRUDiC) and Sudden and Unexpected Postnatal Collapse (SUPC)) should follow national statutory guidance, including a JAR/PRUDiC process or equivalent, with arrangements tailored to the circumstances and place of collapse or death.¹³
The framework gives neonatal-specific examples of circumstances in which a JAR/PRUDiC process should be considered, including:
- a baby born at home without medical professionals present who subsequently dies or is thought to be stillborn
- a sudden death with no immediately apparent medical cause
- circumstances raising suspicion that the death may not have been natural.
BAPM states that a JAR/PRUDiC should also be triggered where a baby is successfully resuscitated following such events but is expected to die in the following days. In those circumstances, the response should be considered at the point of presentation, rather than at the point of death, to allow accurate history-taking and, where necessary, a ‘scene of collapse’ visit. Where there is uncertainty, the framework advises discussion with the designated doctor for child death as part of immediate decision-making.
The framework also refers to BAPM guidance on SUPC, noting that it may be used in specific circumstances but should not be relied upon in isolation.

Child Death Review meetings and investigation

The framework sets out expectations for Child Death Review meetings and associated investigations, including:
- review of individual neonatal deaths and identification of unexpected findings
- investigation of clusters of deaths or increased mortality rates
- notification to the coroner where investigations identify previously unknown factors that may have contributed to a death
- alignment between local reviews, statutory notifications and national safety processes.
The framework includes a timeline covering actions before death and up to at least three months afterwards, encompassing family-focused actions, staff actions, investigations, and statutory or national notifications.¹⁴

Governance, leadership and resourcing

BAPM sets out expectations for leadership and resourcing of neonatal mortality governance, including:
- designated consultant and senior nursing leads for mortality governance with dedicated time for Child Death Reviews, thematic reviews and dissemination of learning¹⁵
- recommended job planned time for medical, nursing and administrative roles, scaled according to unit type (NICU, LNU or SCU)¹⁶
- training requirements for staff involved in end-of-life care, including completion of Sands neonatal bereavement care pathway training as a minimum standard.¹⁷
All of this may be very sound. It should be assessed by Trusts and NHS England. It should inform decisions about leadership and resourcing. Compliance should be part of any CQC inspection.

Paediatric and perinatal pathologists

A long-standing staffing shortage has become a crisis in the provision of paediatric and perinatal pathology services.
Perinatal pathologists study disorders of the placenta, problems affecting unborn babies’ development, and causes of miscarriage, stillbirth and neonatal (newborn) death. Paediatric pathologists investigate illnesses affecting children up to 18 years of age. Paediatric pathologists are experts in unique childhood diseases. Their work includes post-mortems.¹⁸
The latest Paediatric and Perinatal Pathology Workforce Report, published by the Royal College of Pathologists in November 2025, declares a “workforce crisis”.¹⁹ The key findings are:
- The UK has 52 paediatric and perinatal pathology consultants working as 46.35 whole-time equivalents (WTE): 43 in England, 7 in Scotland and 2 in Wales.²⁰
- There are no paediatric and perinatal pathology consultants working in Northern Ireland. In England, in the South West and the Midlands, shortages have led to total service collapses.²¹
- Currently, 37% of paediatric and perinatal pathology consultant posts in the UK are vacant.
- Recruitment is almost impossible due to a national shortage of qualified candidates; 83% of paediatric and perinatal pathology consultants report issues with recruitment in their departments.
- Only 3% of paediatric and perinatal pathology consultants believe that current staffing levels are adequate to ensure the long-term sustainability of their service.
- Within the next five years, 25% of the consultant paediatric and perinatal pathology workforce are expected to retire.
- There are only 13 resident doctors in paediatric and perinatal pathology specialist training posts. This is insufficient to address any of the following: long-standing vacancies, expected retirements and future needs.
- Bereaved families are facing a major increase in waiting times – and/or transfer out of their region – for post-mortem examination of their babies and children: 1 in 5 are now waiting 6 months or more, and some longer than 12 months.
As well as a shortage of consultants, demand for services has increased over the last six years.²²
In its report, the Royal College of Pathologists calls for:
- phased expansion of training posts up to 37 by 2030
- increased protected time and funding for professional development so consultants have time to train the next generation
- increased workforce support with dedicated biomedical scientists, anatomical pathology technicians (assistants to pathologists) and administrative support in each paediatric pathology unit
- committed funding and resources to continue the development of ten fellowships
- an advanced training programme in paediatric and perinatal pathology
- upskilling of scientists and histopathologists to engage in placenta reporting and commitment to resource and prioritisation of the specialty.
The government response in April 2026 points to the launch of a national programme to strengthen perinatal and paediatric pathology services and to improve service capacity and resilience. A £20,000 recruitment incentive for new trainees has been introduced, a fully funded international recruitment campaign has been launched, and a new National Training Programme Director has been appointed.²³
On 8 April 2026, in answer to a written question in Parliament about the steps taken in light of the report, Gillian Merron, Baroness Merron, said this:
“The paediatric and perinatal pathology workforce report highlights the extent of the workforce crisis in paediatric and perinatal pathology and the impact this can have on turnaround times and families.
NHS England has launched a national programme to strengthen perinatal and paediatric pathology services and to improve service capacity and resilience.
A £20,000 recruitment incentive for new trainees has been introduced, a fully funded international recruitment campaign has launched, and a new National Training Programme Director has been appointed.
Further initiatives are underway to review the training pathway, develop advanced practitioner roles, and implement a retention strategy for existing staff.”²⁴

This looks very promising, assuming the £20,000 incentive will attach to all new trainees with the aim of reaching 37 training posts by 2030. There is no commitment to the latter number. I also note that the Royal College of Pathologists’ workforce report stated: “A previously introduced £20,000 recruitment incentive for new residents has now stopped.” The incentive must not be removed until workforce requirements are met.

I recommend that a clear timetable is set and followed so that, by June 2030, there are 37 doctors in training posts as paediatric and perinatal pathologists. Funding must be made available to pay the £20,000 incentive to each new trainee with clear provision for the repayment of the £20,000 in the event the trainee does not complete training or takes up employment outside the NHS within five years of completing training.