Charlotte Davies (2007) instructed on behalf of the Local Authority at inquest into death of 9-month old girl

Charlotte Davies (2007) represented Cornwall Council at a three-day inquest before the Senior Coroner for Cornwall & the Isles of Scilly into the death of a 9-month old girl at Royal Cornwall Hospital, Treliske, Truro, in 2024.

Izzah Ali died of heart failure caused by profound anaemia. Her anaemia was a result of her having been fed cow’s milk from four months old. Cow’s milk not only does not contain iron, like breastmilk or formula does, but also prevents the absorption of dietary iron. A document entitled “The Essential Guide to Feeding Your Baby” had been provided to the parents. The guide was available in English only and moreover did not expressly state that cow’s milk was contraindicated for babies under the age of one.  There were also concerns around the use of the term “bottle fed” being assumed to mean “formula fed”. Steps have been taken by Cornwall Council to address these concerns and raise awareness around language barriers as well as baby feeding practices within different cultures, with a new weaning guide being produced. The guide will be available in a number of languages.

Charlotte acted for the health visiting service (part of Cornwall Council) which had undertaken the post-birth and six-week visit, during which the child was said to be solely breastfed and thriving. Given there were no concerns, the family were placed on the Universal Pathway.

During a visit to RCH, a urinary tract infection was diagnosed, but anaemia was not. The Senior Coroner found it more likely than not that Izzah had developed anaemia by this point and this was the cause of her pallor and distended abdomen. A month later she was admitted to RCH and it was established that she was profoundly anaemic. She was treated by blood transfusion but collapsed and suffered cardiac arrests. She could not be resuscitated.

Evidence was heard from the allocated Health Visitor, the Named Nurse for Safeguarding, the Interim Director for Midwifery, the pathologist, and a number treating doctors and consultants from both the Minor Injuries Unit and Royal Cornwall Hospital. Further medical evidence was read into the inquest.

The Senior Coroner returned a narrative conclusion finding that Izzah died from complications caused by her treatment for profound iron-deficiency anaemia in turn due to her consumption of cow’s milk.

Prevention of Future Death Reports to be served on Royal Cornwall Hospital and Cornwall Council.

Charlotte has a specialist inquest practice and has appeared in numerous multi-day inquests representing all types of interested parties, including Article 2 and jury inquests. She has appeared in a number of inquests reported in the national press, including those involving Leading Counsel. She has written a series of articles on Inquest Basics which can be found on our website and on LinkedIn. 

If you wish to discuss anything in this article or you want to instruct Charlotte you can contact her clerk on civilclerks@kbgchambers.co.uk