2026-0178
25 Mar 2026 · Coroner Fiona Wilcox · Inner West London
The coroner's concerns
1. perfunctory scene examination leading to lost forensic opportunities
“That child death investigation teams are too easily reassured when they attend deaths and find a well-presented home environment with no overt signs of neglect or injury to the deceased child, such that the scene examination becomes perfunctory and forensic opportunities are lost.”
2. feeding bottles and equipment not seized
“That feeding bottles and equipment are not routinely seized pending toxicology results.”
3. insufficient consideration of poisoning role
“That insufficient consideration is given the potential role of poisoning in such deaths by the police.”
4. outdated police training and guidelines
“That police training and guidelines may need to be updated.”
5. nannies administering chlorpheniramine to children
“That nannies should be specifically trained not to administer piriton or other chlorpheniramine containing substance to a child except on medical advice and with full knowledge and agreement of parents.”
6. chlorpheniramine administration linked to sudden child death
“That there are international reports linking administration of chlorpheniramine and sudden death in children, but this is an area of evolving knowledge, and it may assist understanding if the NCA were to review case files nationally to establish whether in other cases of unexpected child death chlorpheniramine had been administered.”
7. illicit chlorpheniramine administration by nanny still employed
“That a person whom the court found administered chlorpheniramine illicitly to a child and that administration possibly contributed to that child's death is still working as a nanny.”
8. absence of national nanny regulation
“That there is no national regulation system for nannies.”
9. inadequate product warning about chlorpheniramine risks
“That the warning information on products containing chlorpheniramine, such as piriton may need to be updated to include the association between administration of the substance and sudden unexpected death in children.”