Following the conclusion of the inquest into the tragic death of Ida Lock, our Trust was issued with a Prevention of Future Deaths (PFD) notice by Dr Adeley, the senior coroner for Lancashire and Blackburn with Darwen.
The PFD notice covered four key areas for the Trust to consider in its response: a culture of candour; clinical governance and maternity governance; mandatory training, expired training and remedial training; and grading of harm for incident reporting, particularly for babies who have suffered hypoxic brain injuries and undergone cooling.
We submitted our formal response to the PFD notice on 16 May 2025. This response reflects the changes already made and an action plan outlining changes that will be made as a result of these findings. We made a commitment to being open and transparent with our response and are sharing it publicly today after giving the family some time to review privately.
Aaron Cummins, Chief Executive, UHMBT, said: “We would like to express our deepest condolences to the parents and family of Ida. We want to apologise for the lapses in care that resulted in her tragic death and the further harm we then caused by how we handled the investigation. We recognise the distress this has caused Ida’s loved ones and are truly sorry for this.
“We fully accept the findings of the coroner and have reviewed our practices, policies and procedures in light of these, so that we can identify where further changes need to be made.
“As an organisation we are committed to learning from this tragic event and the issues identified during the inquest to make sure we do not repeat these mistakes and cause harm to any other families.”