“Cassian's parents were not told about the Consultant Plan to review, reassess and pull…”

The coroner’s concerns

– 1. Cassian's parents were not told about the Consultant Plan to review, reassess and pull back Cassian's central line. Whilst this was not Cassian's parents’ responsibility, had they known about it they would have acted as a prompt for staf f on a busy ward. 2. I heard evidence that the staffing levels on the Jessops Wing are over the national requirements. This therefore led to an assumption that staffing was not an issue or a f actor which led to the failure to document Cassian's requirement f or review. However, there is a possibility that the number of staff placed an additional burden on the consultant (more junior staff means more questions) and that f ewer staff may have offered greater consistency. 3. I heard evidence that the pink sheets have been reviewed and redesigned f ollowing Cassian's death and are now more directive. I also heard evidence that these f orms are more detailed than the national requirements. Again, there does not seem to have been consideration of whether the national form would actually meet the requirements of this unit and that less information may be pref erable in these circumstances. 4. I heard about the Jessops Unit having responsibility, not only for babies already in the unit but also for some of the sickest and most premature babies in the region. I did not hear any evidence of how the Jessops Unit access support from colleagues across the region. I heard evidence of trying to access colleagues to support the Jessops Unit directly and a buddy system but there are other neonatology consultants across the Region who could provide remote assistance potentially if encouraged to think as a system.

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, 2022-0120

Added to Minute Book

8 Oct 2026

Reuse

We show short extracts and link to the original. We don’t host the full report.

Something wrong, such as a date or who it was sent to? Report a mistake

Is this report about someone close to you? You can ask us to remove names from our pages.

Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0