5. The College of Paediatricians Finds No Evidence of Intentional Harm

The Royal College of Paediatric and Child Health (RCPCH) has been “invited to review the investigations of each death and the wider service, including network support and advice, protocols and transfer arrangements, to provide a view on whether there were any contributory factors in the deaths or missed opportunities to take action that could have prevented or mitigated them”. The report identifies failings on the unit and makes 22 recommendations that it said should be implemented before a reinstatement of the unit as an LNU should be considered.