Isla McVeigh

Dear HM Assistant Coroner Cohen, Inquest concerning the death of Miss Isla McVeigh Cumberland Council write in response to the Regulation 28 Report issued by HM Assistant Coroner Cohen, dated 23rd July 2026, following the Inquest of Miss Isla McVeigh. Both Cumberland Council and Cumberland Safeguarding Children Partnership would like to extend sincere condolences to Miss McVeigh’s family. Acknowledgement of the Concern Raised Cumberland Council and the Cumberland Safeguarding Children Partnership acknowledge the concern identified at paragraph 10(3) of the Prevention of Future Deaths Report: "The threshold for involving local authority social care is too high in practice." \Ne recognise the evidence heard during the inquest that some safeguarding professionals considered concerns relating to parental opiate dependency may not have met the threshold for referral to Children's Social Care and that, in their experience, referrals in comparable circumstances may not have been accepted. 1

[Page 2] Cumberland Children and Family Wellbeing Cumbria House 117 Botchergate Cumberland Council Carlisle Cumbria CA1 1RD cumberland.gov.uk We share the Coroner's commitment to ensuring that children receive the right help and protection at the earliest opportunity. We recognise the importance of understanding whether any aspect of local safeguarding arrangements could unintentionally discourage or delay referrals where concerns are identified. Practitioner confidence and understanding of safeguarding pathways are essential to effective multi-agency safeguarding practice. Review of Cumberland Safeguarding Children Partnership Multi-Agency Threshold Guidance and Associated Arrangements Through the Cumberland Safeguarding Children Partnership, we will undertake a review of: Multi-Agency Threshold Guidance; The Understanding the Level of Need and Practice Response document; The Multi-Agency Pre-Birth Protocol; and Associated referral, consultation and escalation arrangements. The review will consider whether any aspect of current guidance could be interpreted as requiring an unnecessarily high level of risk before referral to Children's Social Care is considered and whether further clarification is required in light of the themes identified during the inquest. The review will also consider whether existing guidance sufficiently supports practitioners to recognise and respond to cumulative risk, professional uncertainty and circumstances where early referral, consultation or assessment may be appropriate to safeguard children. 2

[Page 3] Cumberland Children and Family Wellbeing Cumbria House 117 Botchergate Cumberland Council Carlisle Cumbria CA1 1RD cumberland.gov.uk Any amendments identified through this review will be progressed through the governance arrangements of the Cumberland Safeguarding Children Partnership. Timescale: Review to commence in October 2026 and conclude by January 2027. Any amendments identified will be implemented following partnership approval. Multi-Agency Learning and Engagement The Cumberland Safeguarding Children Partnership will undertake engagement with safeguarding professionals across health, education, police, children's social care and wider partner agencies to better understand the concerns raised during the inquest and to strengthen a shared understanding of referral expectations and safeguarding responsibilities. This work will reinforce: the importance of professional curiosity and professional judgement; seeking consultation where there is uncertainty regarding thresholds; ensuring referrals are not delayed because of uncertainty regarding statutory thresholds; considering concerns cumulatively rather than in isolation; and the use of established escalation and professional challenge arrangements where concerns remain. Learning arising from the inquest will be shared through safeguarding partnership governance structures, multi-agency forums and workforce development arrangements. 3

[Page 4] Cumberland Children and Family Wellbeing Cumbria House 117 Botchergate Cumberland Council Carlisle Cumbria CA1 1RD cumberland.gov.uk Timescale: Multi-agency engagement and dissemination of learning to be completed by January 2027. Actions to Address the Matter of Concern In response to the concern identified by the Coroner, Cumberland Council and the Cumberland Safeguarding Children Partnership will: Review threshold guidance and associated safeguarding procedures. Review referral, consultation and escalation arrangements. Undertake multi-agency engagement to strengthen shared understanding of referral expectations and safeguarding responsibilities. Reinforce professional curiosity, professional challenge and escalation processes across the partnership. Share learning arising from the inquest through governance, quality assurance and workforce development arrangements Overall completion date: Initial actions by January 2027, with review activity and implementation completed by March 2027. We trust that the above will reassure the Coroner, however, if any of the above information needs to be clarified, please do not hesitate to contact us.

Dear Mr Cohen, Thank you for your Prevention of Future Deaths Report following the inquest into the death of Isla Alma McVeigh. Firstly, on behalf of North Cumbria Integrated Care NHS Foundation Trust, I would like to extend our sincere condolences to Isla’s family following their tragic loss. We have carefully considered the findings of the inquest and the concerns raised within the Prevention of Future Deaths Report. We recognise the importance of ensuring that the learning arising from this case is fully embedded across our services and are committed to implementing the necessary actions to strengthen clinical practice, safeguarding processes, professional curiosity, and multi-agency working in order to reduce the risk of similar incidents occurring in the future. We have reviewed the matters of concern raised by you, namely: Clinicians’ understanding of codeine dependence and the risks associated with prescribed opioid use. The need for greater professional curiosity in relation to opioid dependence and misuse. Understanding and application of safeguarding referral thresholds and escalation processes. The Trust accepts the concerns identified within the Prevention of Future Deaths Report and has developed a comprehensive action plan to address these. The action plan is structured around four key learning themes: Recognition of Codeine Dependence and Opiate Misuse Risk; Professional Curiosity Around Substance Use; Understanding Safeguarding Thresholds and Escalation; and Care of Babies with Neonatal Abstinence Syndrome. Key actions include: Mandatory safeguarding, professional curiosity, and opioid dependency awareness briefings for maternity, neonatal, and paediatric staff. Pillars Building, Cumberland Infirmary, Infirmary Street, Carlisle, Cumbria, CA2 7HY 01228 523444 www.ncic.nhs.uk Safe, high quality care every time

[Page 2] Incorporation of simulation-based learning and case studies arising from the Coroner’s findings into annual training programmes to strengthen recognition of opioid dependency, safeguarding assessment and escalation of concerns. Review and update of clinical guidance relating to the management of pregnant women using prescribed and non-prescribed opioids. Enhanced safeguarding supervision processes to support reflective learning and professional curiosity. Explore the safeguarding threshold with the wider safeguarding partnership and implement changes in practice to local policy. Review of neonatal abstinence syndrome care pathways and strengthening of discharge processes, including safeguarding review and safe sleep considerations. Auditing of cases involving neonatal abstinence syndrome to provide assurance regarding safeguarding assessments, referral decisions and escalation practice. Delivery of the action plan will be overseen through the Trust’s governance arrangements, with progress monitored by the Patient Safety Group and reported through established quality and safety structures. We are committed to working collaboratively with safeguarding partners to ensure that the lessons identified from this tragic case result in meaningful and sustained improvements in practice, thereby reducing the risk of similar events occurring in the future. Please find enclosed the Trust’s detailed action plan in response to the Prevention of Future Deaths Report.