“A theme that emerged during the evidence was the repeated reference to Izzah being…”
Dated 11 Dec 2025, from the coroner for Cornwall and the Isles of Scilly. Sent to 4 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
Deadline passedReplies were due by 5 Feb 2026. A reply may have been sent and not yet published.
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.
- Report dated11 Dec 2025
- Deadline5 Feb 2026
- Published on judiciary.uk18 Dec 2025
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Royal Cornwall Hospitals NHS TrustNamed in the report as “Royal Cornwall Hospital” | Response publishedPublished on judiciary.uk in December 2025. |
| Cornwall Council | Response publishedPublished on judiciary.uk in December 2025. |
| Integrated Care Board | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 5 Feb 2026. A reply may have been sent and not yet published. |
| Cornwall Partnership NHS Foundation Trust | Response publishedPublished on judiciary.uk in December 2025. |
The 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 2 Information Classification: CONTROLLED 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. 6 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.
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, 2025-0623
- Added to Minute Book
- 8 Oct 2026
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- 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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