Recurance · prevention of future deaths reports
Pre-inquest brief
Insufficient complex neonatal resuscitation training
The earlier warning
Luca Yates · 9 Nov 2023 · Chris Morris, Manchester South
“It is a matter of concern that Consultant general paediatricians of the future will have a lower level of experience than is currently the case of complex neonatal resuscitation”
judiciary.uk/…/luca-yates-prevention-of-future-deaths-report
What was promised
Stated action 1 · response to Luca Yates (9 Nov 2023) · stated timescale: none stated
“introduced a formal supervisor assessment that the trainee is ready to be on the tier 2 rota with remote supervision (i.e., a consultant on call from home). To agree that a trainee is ready for this step there needs to be agreement that there is evidence of: - Neonatal capabilities. - General paediatric capabilities. - Neonatal Life Support & Advanced Paediatric Life Support course, or equivalent. - Mandatory procedures (including airway maintenance”
judiciary.uk/…/2023-0437-Response-from-Royal-College-of-Paediat…
What recurred
- 10 Feb 2025 · Yahya Hayat · Peter Merchant · Identical hazard · confidence 0.96 (high)
The clearest link, quoted from both reports:
Earlier · Luca Yates · 9 Nov 2023
“It is a matter of concern that Consultant general paediatricians of the future will have a lower level of experience than is currently the case of complex neonatal resuscitation”
Later · Yahya Hayat · 10 Feb 2025
“Consultant general paediatricians of the future will have a lower level of experience than is currently the case of complex neonatal resuscitation”
What happened next
No web check of the stated actions has been published for this chain.