“The apparent inadequacies of the present algorithm in assessing ill newborns/ infants…”
Dated 12 Jun 2025, from the coroner for Oxfordshire. Sent to 2 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 7 Aug 2025.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
- Report dated12 Jun 2025
- Deadline7 Aug 2025
- Published on judiciary.uk30 Jul 2025
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| South Central Ambulance Service NHS Foundation TrustNamed in the report as “South Central Ambulance Service” | Response publishedPublished on judiciary.uk in July 2025. |
| NHS England | Response publishedPublished on judiciary.uk in July 2025. |
The coroner’s concerns
– (1) The apparent inadequacies of the present algorithm in assessing ill newborns/ infants, particularly in identifying significant respiratory problems that require early clinical assessment (2) Total reliance on the algorithm which does not appear to direct early clinical input. (3) A delay/lack of direction in obtaining clinical assessment. I have concerns that this is widespread and could occur in other areas.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2025-0392
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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