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Dear Professor Wilcox Prevention of Future Deaths – On behalf of the Commissioner of Police of the Metropolis, I write to provide the response to the matters of concern addressed to the Metropolitan Police Service (“MPS”) in your Report to Prevent Future Deaths, dated 25th March 2026, following the inquest into the tragic death of May I first express my sincere condolences to the family of , our thoughts and sympathies are very much with them. The MPS has acknowledged and reviewed all matters of concern raised in your Regulation 28 Report and responds as follows. Matter of Concern 1 “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.” MPS Response The investigation of a child death is complex and emotionally demanding, requiring police officers to balance empathy and sensitivity with the professional necessity of conducting a thorough, detailed, and open-minded investigation. For this reason, the policing response to sudden unexpected deaths in infancy is deliberately predicated on an investigative mindset, regardless of the apparent presentation of the home environment or caregivers at the time of attendance.

[Page 2] At the time of death, MPS policy followed national guidance set out in Association of Chief Police Officers (ACPO) (2014) A Guide to Investigating Child Death, which emphasised the importance of maintaining professional curiosity, developing, and testing investigative hypotheses, and avoiding premature conclusions. That guidance makes clear that investigative thoroughness must not be influenced by perceptions of family presentation, socio-economic context, or the absence of visible injury. These principles underpin police practice and are embedded within child death investigation processes. After death, in December 2024, this approach was further reinforced through the introduction of the National Police Chiefs’ Council (NPCC) Practice Advice on Child Death Investigation, which refreshed and strengthened national guidance. The Practice Advice places continued emphasis on professional curiosity, encouraging officers to ask appropriate questions, reflect critically on information received, maintain an open mind, and avoid accepting initial accounts or assumptions at face value. It also provides clearer direction on the conduct of scene examinations, and MPS policy was updated in May 2025 to reflect the key expectations set out within this guidance. These expectations have been reinforced through training since May 2025, following implementation of the College of Policing Investigating Sudden Unexpected Death in Childhood programme, which specifically addresses the risk of unconscious bias and the potential for false reassurance when officers encounter a well-presented home or apparently attentive carers. The programme emphasises the importance of maintaining an open and questioning mindset, recognising that neglect, harm, or the administration of harmful substances can occur in any family context. It reinforces the need for systematic scene examination and the preservation of forensic opportunities in all cases, irrespective of initial impressions. Since May 2025, seventy-nine MPS officers have attended this training. Seven more courses are scheduled to take place over the next twelve months, which will mean an additional eighty-four specialist officers being trained. The MPS recognises the importance of continuing to emphasise these principles and of remaining alert to the impact of early perceptions at the scene of child deaths. A careful, methodical approach to initial enquiries, including scene examination, is integral to ensuring that investigative and forensic opportunities are not overlooked, and this remains embedded within police policy, training, and practice. Matter of Concern 2 “That feeding bottles and equipment are not routinely seized pending toxicology results.”

[Page 3] MPS Response The ACPO (2014) Guide to Investigating Child Deaths, which constituted the relevant national guidance at the time of death, does not make specific reference to the seizure of unused feeding bottles. It does, however, direct officers to locate and preserve bottles relevant to establishing a child’s feeding history and expressly refers to securing bottles that have been used, or may have been used, to administer food or substances. MPS policy in force at that time was aligned with this guidance and informed officers’ decision-making in relation to the identification and preservation of feeding equipment. Subsequent national guidance, introduced through the NPCC Practice Advice on Child Death Investigation in 2024, represents a development in practice. This refreshed guidance provides more detailed direction on the consideration of feeding bottles within the home environment, including those that are prepared or ready for use, and places clearer emphasis on their potential seizure as part of early scene assessment and enhanced toxicology analysis. In addition, the College of Policing Investigating Sudden Unexpected Death in Childhood programme, delivered to police investigators nationally, including officers in the MPS, highlights the importance of seizing used feeding bottles and containers, whether empty, partially consumed, or unused. It draws on learning from cases in which children were deliberately given harmful substances to cause harm, to reinforce these investigative principles. Following the inquest of MPS policy has since been reviewed and updated to reflect the national guidance and training, which emphasises the importance of seizing bottles and equipment should enhanced toxicology analysis be required. Matter of Concern 3 “That insufficient consideration is given to the potential role of poisoning in such deaths by the police.” MPS Response The MPS recognises the potential role of poisoning or ingestion of harmful substances in the investigation of sudden and unexpected infant deaths and understands the Coroner’s concern that such factors may not always be given sufficient consideration. MPS policy requires investigators to consider a range of relevant criminal offences when investigating the death of a child, including the offence of child cruelty under section 1 of the Children and Young Persons Act 1933. That offence expressly encompasses ill-treatment and exposure, within which the deliberate or negligent administration of harmful substances, including medication, would fall.

[Page 4] Investigative guidance further emphasises the early identification and preservation of evidential material that may indicate poisoning or ingestion. This includes the seizure of bottles, feeding equipment, clothing, nappies, medication, and any substances that may have been ingested by the child, including liquid medicines, alcohol, or other fluids, to ensure that opportunities to identify toxic or harmful substances are not missed at the outset of the investigation. National guidance supports this approach. The NPCC Practice Advice on Investigating Child Deaths (2024) highlights the importance of toxicology, including enhanced toxicological analysis, where there is any indication that substances may have been ingested or contributed to a child’s death. In addition, the College of Policing Investigating Sudden Unexpected Death in Childhood programme, delivered to police investigators nationally, including officers in the MPS, emphasises professional curiosity and the need to consider poisoning or ingestion of harmful substances during the initial investigation. Training delivery clearly explains relevant legislation, including S23 Offences Against the Persons Act 1861 and details the types of substances that investigators need to be aware of, including oxygen, salt, and incorrect doses of medication, like insulin which could cause harm to the child. Investigators are also aware through the training, that detection of any substance will be found through blood examination in the post-mortem and should, therefore, be considered when attending the death of a child, where there are no apparent circumstances. The training highlights the importance of seizing used feeding bottles and containers, whether empty, partially consumed, or unused and securing all medications present. It draws on learning from cases in which children were deliberately given harmful substances to cause harm, to reinforce these investigative principles. MPS policy was updated in May 2026 to make specific reference to poisoning and ingestion of harmful substances, reflecting national learning from cases including Daniel Pelka and Arthur Labinjo-Hughes and reinforcing awareness of toxicological considerations in sudden and unexpected child deaths. This change reflects the MPS’s consideration of the Coroner’s observations and supports the ongoing emphasis on early professional curiosity where poisoning or ingestion may be a factor. Matter of Concern 4 “That police training and guidelines may need to be updated.” MPS Response

[Page 5] The MPS has carefully considered this concern. As outlined in the responses above, at the time of death, MPS policy and training reflected the national guidance then in force, which emphasised professional curiosity, the avoidance of premature conclusions, and the need for thorough scene examination and evidence preservation in all sudden and unexpected child deaths. Those principles were embedded within police practice and reinforced through specialist training. Since that time, national guidance and learning have developed. The introduction of the NPCC Practice Advice on Child Death Investigation (December 2024) refreshed and strengthened expectations around initial investigative mindset, scene examination, seizure of relevant items, consideration of toxicology and the risk of bias arising from early impressions of the home environment or caregivers. In response, MPS policy has been reviewed and updated to reflect this updated national guidance, including clearer reference to poisoning and ingestion of harmful substances and enhanced direction on the handling of feeding equipment and other potential evidential material. Training delivered to investigators, including the College of Policing Investigating Sudden Unexpected Death in Childhood programme, continues to reinforce these principles. The programme addresses unconscious bias, the dangers of false reassurance, and the importance of maintaining an open mind and a methodical approach irrespective of family presentation or socio-economic factors. This training remains central to the development of officers undertaking child death investigations. Taken together, the updates to national guidance, corresponding amendments to MPS policy, and the continued emphasis within professional training serve to address the Coroner’s concern. The MPS remains committed to keeping its policies and training under review to ensure they reflect emerging learning and best practice in the investigation of sudden and unexpected child deaths. Please do not hesitate to contact me should you require further information.

Dear HM Coroner Professor Wilcox, Re: Regulation 28: Report to Prevent Future Deaths, Baby O. Thank you for your report into the tragic death of Baby O. Please allow me to extend my condolences to the family and friends of Baby O and acknowledge the matters of concern set out in section 5 of your report, and our duty to respond. I have outlined the matters of concern that appear to be related to the College of Policing, so that I can provide you with a comprehensive response for each.
1. 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. The College of Policing offers a national, Investigating Sudden Death in Childhood Course, which was reviewed and re-launched in 2025, and which is available to all Home Office forces. The programme has been developed for Lead Investigators who have the responsibility for conducting investigations following the sudden, unexpected death of a child. Those who attending the course should have previously completed Professionalising Investigation Programme (PIP) level 2 or level 3 learning and registration. The course reflects the 2024 National Police Chief’s Council (NPCC) Practice advice on child death investigation and provides delegates with the knowledge to conduct thorough and impartial investigations. Referenced by the College of Policing, the national guidance also stresses the need to safeguard against bias, stereotypes, and assumptions, particularly in emotionally charged or ambiguous circumstances. The College of Policing also uses Authorised Professional Practice to underpin key facets of this approach, and more details, including the link to the current Practice Advice on Child Death Investigation can be found here. More widely, the College of Policing has developed a variety of tools and approaches to help officers and staff with decision making, promote professional curiosity, and to prevent or mitigate against biases, assumptions or stereotypes when dealing with an investigation or wider policing matter. The use of the National Decision Model (NDM), and the Code of Ethics, which sits at the centre of the NDM, underline

[Page 2] the critical importance of making well considered and appropriately recorded decisions. First introduced in 2013 and updated in January 2024, the NDM supports officers to structure decisions, assess risk, consider alternative options, and ensure that decisions are lawful, proportionate, accountable, and ethical, particularly in complex and high-pressure situations where objectivity, challenge and reflection are essential. These expectations are reinforced by guidance for conducting effective investigations (Conducting effective investigations guidelines, published in August 2023), Guideline 2, making good decisions, in particular, highlights the risks of confirmation bias and encourages open-minded hypothesis generation and reflective decision-making.
2. That feeding bottles and equipment are not routinely seized pending toxicology results. The current NPCC Practice Advice on Child Death Investigation, stresses the need to “check throughout the house for feeding bottles (used or readymade),…..These items should be seized.” (P,30). The guidance also advocates wider good practice relating to scene management and the prevention of or disposal of potential evidence.
3. That insufficient consideration is given the potential role of poisoning in such deaths by the police. In addition to the points made under Concern 1, the College’s Investigating Sudden Death in Childhood Course places emphasis on professional curiosity at the earliest stages of an investigation. The training highlights the need to keep an open mind and to actively consider whether poisoning or the ingestion of harmful substances, where no obvious cause of death, could have taken place. It provides clear guidance on relevant legislation, including Section 23 of the Offences Against the Person Act 1861, and outlines a range of substances that investigators should be alert to, such as oxygen, excessive salt, and incorrect dosages of medication (for example, insulin), all of which have the potential to cause serious harm to a child. The Investigating Sudden Death in Childhood Course forms part of, and builds on the wider investigative skills programme. Beginning in 2003, College’s Professionalising Investigations Programme delivers a professional, ethical and effective investigation capacity for all levels, including those who would investigate unexpected and/or suspicious deaths; where consideration of poisoning and other criminal causes of death are covered.
4. That police training and guidelines may need to be updated. While I am satisfied that current police training and practice advice do cover the crucial issues kindly raised. I would also like to reassure you that we will work closely with NPCC colleagues, to consider whether further strengthening of the approach advocated is required. This includes ensuring that both the practice advice and training are aligned in all areas.

[Page 3] The College of Policing has recently also launched a consultative period for our revision of Child Abuse Authorised Professional Practice (APP). I will ensure that the team proactively considers whether greater alignment between the practice advice on child death investigations and the APP on child abuse is required. If you would like to explore any of the response areas provided above, or have any other questions or queries, please do not hesitate to contact my Crime and Criminal Justice Delivery Lead, DCS J at

Dear Professor Fiona J Wilcox, I write on behalf of Haleon UK Trading Limited in response to the Regulation 28 Prevention of Future Deaths Report. Our response addresses those matters of concern that relate to Haleon and Piriton-branded products, given the references to Piriton included within the report. We recognise the seriousness and sensitivity of this matter, and offer our deepest sympathies to the family and all those affected.
1. Product identification and inquest conclusion We note that the Report is not conclusive about the specific product that was administered to the infant. We also note that the Coroner's investigation records the cause of death as unexplained, and that no further product-identifying information is provided to establish that a Haleon product was involved. For completeness, we also note that the active ingredient name is not the same as the brand name. In particular, chlorphenamine (also known as chlorpheniramine) is the relevant active ingredient in Piriton-branded products as well as other branded and generic antihistamine products; however references to "trade name usually piriton" do not, of themselves, confirm either the product or the active ingredient administered.
2. Consumer information, suitability and age Without commenting on the specific circumstances of the case, we would reiterate the following points: Before taking or giving any medicine, consumers should always read the product label carefully and seek advice from a healthcare professional if they are unsure whether a product is suitable. Chlorphenamine-containing products, such as Piriton Syrup, are not intended for children under 12 months, while Piriton Allergy Tablets are not intended for children under 6 years old. In the UK, Piriton products are pharmacy only medicine, meaning the products are Haleon UK Trading Limited Registered Office Registered in England and Wales Haleon UK Trading Limited No. 09237643 5 The Heights Wellington Way Weybridge Surrey, KT13 ONY United Kingdom

[Page 2] HALEON Continued Page 2/2 only sold under the direction of a pharmacist, offering suitable advice and directions for use at the point of purchase. In compliance with applicable regulatory standards, Piriton products in the UK include clear dosing and age-range instructions. For example, Piriton Syrup includes leaflet statements such as "Do not take more than the recommended dose" and "Do not give to children under 12 months." Actions taken: Haleon has completed a focused review of how the relevant age restriction messaging is presented across UK-facing materials within its control (e.g., the outer packaging, product label, patient information leaflet, product website). Conclusion: All Haleon's labelling conform with the UK Human Medicines Regulation 2012 and relevant guidelines from the Medicines and Healthcare products Regulatory Agency (MHRA) - and Haleon is continuously committed to compliance with current and updated legislations.
3. Safety reporting and ongoing safety oversight Actions taken: In line with pharmacovigilance reporting obligations and internal processes, we have created a safety report with the information available to us from the Coroner's Report, notwithstanding that it has not been established that a Haleon product was administered, and no further information is provided in the Report to confirm product identification. Ongoing: Product safety is one of Haleon's primary priorities. We keep the safety of our products and related risk communications under continuous review in accordance with our governance processes and applicable regulatory requirements.
4. Closing Product and consumer safety are our utmost priorities, and we trust the above addresses the matters of concern relevant to Haleon that are raised in the report. We also kindly suggest that the Medicines and Healthcare products Regulatory Agency is the correct addressee regarding calls for product labelling changes. If you require any further information or clarification, please let us know and we will respond promptly. You sincerely-; Legal & Compliance Lead Counsel UK&I and Nordics For and on behalf of Haleon UK Trading Limited Haleon UK Trading Limited Registered Office Registered in England and Wales Haleon UK Trading Limited No. 09237643 5 The Heights Wellington Way Weybridge Surrey, KT13 ONY United Kingdom