The findings from the reports – one commissioned by NHS England (South Central) and NHS Improvement and one by the Buckinghamshire Safeguarding Children Partnership are published online and can be accessed via the links on this page.

Both reports concluded that the deaths could not have been predicted and, as a consequence, could not have been prevented. However, there is learning for a wide range of agencies and improvements. Those relating to the work of Oxford Health NHS Foundation Trust form the basis of an action plan that has since been implemented and is shared here 

Marie Crofts, Oxford Health’s Chief Nurse, said: “We are deeply saddened by the deaths of the young child and her mother and Oxford Health extends its deepest sympathies and condolences to the family and all those affected. We recognise that all investigation processes are particularly challenging for family members and we acknowledge and appreciate their participation to ensure all learning is identified and appropriate actions have been taken.

“An action plan was developed by Oxford Health following our internal Serious Incident investigation with one of the actions being strengthened following the outcome of the external independent investigation commissioned by NHS England and NHS Improvement. A great deal of work has been completed following the tragic deaths and we will continue to monitor the impact of these.”