Fit and wholesome child’s demise branded ‘avoidable’ after being given the improper milk
Nine-month-old Izzah Fatima Ali died at Royal Cornwall Hospital in September 2024 but her death was deemed ‘avoidable’ after a ‘lack of professional curiosity’
A nine-month-old baby tragically died after a language barrier led to complications in her care, an inquest has heard. Izzah Fatima Ali was just nine months old when she passed away at Royal Cornwall Hospital at Treliske, Truro, on September 7, 2024.
An inquest into her death heard she had become progressively ill over several weeks, having been routinely given cow’s milk by her parents who were unaware of the dangers.
Her mother, Mrs Ali, had relocated to Cornwall from Pakistan whilst 30 weeks pregnant and could not speak English. She was therefore dependent on her husband, who was described by nursing staff as exceptionally attentive, supportive and caring towards his wife and child, to interpret during appointments with medical professionals, reports Cornwall Live.
The inquest heard the parents had sought medical help for their daughter on multiple occasions and that during these visits, they informed staff their child was “bottle fed” – however, they were never questioned about what this actually meant.
Andrew Cox, senior coroner for Cornwall and Isle of Scilly, said in his conclusions there was “an element of assumption made here”, which could be characterised as a “lack of professional curiosity.”
He observed that bottle fed could indicate formula or expressed breast milk. In this instance, he said it was expressed cow’s milk, but “no health care professional established that”.
The inquest was told that Izzah’s parents received a council-issued feeding guide – An Essential Guide to Feeding Your Baby – but this was only available in English and lacked information about the dangers of giving cow’s milk to babies.
The coroner observed that a UNICEF version of the guide, which does include that vital information and is available in Urdu, exists but was not provided to the family.
Mr Cox stated that although Izzah’s father possessed “excellent English”, it wasn’t his mother tongue, meaning all healthcare interactions should have taken place with an interpreter present.
However, he noted, this didn’t occur. Giving testimony, pathologist Dr Levine highlighted that introducing cow’s milk during an infant’s first year represents the “greatest dietary risk factor for iron deficiency”.
She clarified that not only does it contain minimal iron, but it also reduces iron absorption from other food sources.
A month prior to Izzah’s death, she appeared pale with swollen eyes and a tender abdomen.
She had also been vomiting daily, and when her parents brought her to Royal Cornwall Hospital, medics discovered a urinary tract infection (UTI) and prescribed antibiotics.
Mr Cox stated in his conclusions that it was highly probable she was already anaemic at that point, yet again no further questions were raised about what Izzah was being bottle-fed. On September 6, 2024, Izzah was readmitted to hospital.
The coroner stated she was discovered to be “profoundly anaemic” and doctors needed to perform a blood transfusion for her to survive.
It was during this procedure that Izzah suffered a “collapse” and experienced cardiac arrests. She could not be revived and passed away on September 7.
Whilst Mr Cox acknowledged that a blood transfusion was the correct treatment, he stated that overall, Izzah’s death was “avoidable”.
He said: “Izzah was a nine month old female infant who had been born fit and well.”
The coroner outlined that Izzah’s parents recognise they fed their daughter cow’s milk as they “believed it would be to her benefit”. However, whilst the danger was well understood by professionals surrounding them, they were not informed of this.
He said: “There were multiple interactions with healthcare professionals when it was noted Izzah was being breast and bottle fed. No inquiry was made to check that bottle fed meant formula fed or otherwise to establish what was in the bottles being given to Izzah. It was not identified that she was receiving cow’s milk until her last admission to hospital.
Speaking on behalf of Cornwall Partnership Foundation Trust, which operates Cornwall’s community hospitals and MIUs, a spokesperson told the inquest several steps have been implemented since to ensure lessons are learnt from Izzah’s death. This includes more targeted enquiries regarding what youngsters are being given to eat where there are worries about nutrition.
A spokesperson for the Royal Cornwall Hospitals NHS Trust said there have been reviews into the circumstances surrounding Izzah’s death with actions including compulsory use of interpreters where English is not a patient’s first language.
The coroner ruled Izzah died from “complications caused by her treatment for profound iron deficiency and anaemia, in turn due to her consumption of cow’s milk”.
He advised that all parties involved should take action and told Izzah’s father, Mr Ali: “What I want to ensure is that all the lessons in Cornwall are learnt and that we take every step we can to ensure there be no repetition of this.”
