Izzah Ali

Date of report: 11/12/2025 Ref: 2025-0622 Deceased name: Izzah Ali Coroner name: Andrew Cox Coroner Area: Cornwall and the Isles of Scilly Category: Child Death (from 2015) This report is being sent to: Education and Children’s Community Health REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO:

1. [REDACTED] , Service Director – Education and Children’s

Community Health

I am Andrew Cox, the Senior Coroner for the coroner area of Cornwall and the Isles of Scilly.

On 9/12/25, I concluded the inquest into the death of Izzah Fatima Ali who died on 7/9/24 at the age of 9 months. I recorded the cause of death as: 1a Acute on chronic decompensated heart failure 1b Cardiomyopathy 1c Iron deficiency anaemia (treated with a blood transfusion) I recorded a conclusion that Izzah died from complications caused by her treatment for profound iron-deficiency anaemia in turn due to her  consumption of cow’s milk. A copy of my full judgment is available upon  request.

Izzah was a nine-month-old female infant who had been born fit and well.  Both of her parents came from Pakistan and her mother had only been in  England for a couple of months before her daughter was born. She did not speak English. An interpreter was not used at ante-natal interactions contrary to  guidance. A guide to feeding your baby was produced in English only and it did not set out that providing cow’s milk to an infant under the age of  one was contra-indicated because it ran the risk of causing iron-deficiency anaemia. I was told the Guide had been withdrawn and was  being re-written. A UNICEF guide that was available in Urdu and which  explained this was not provided. There were two health visitor attendances again without an interpreter  present. At the time of the second attendance, Izzah was still breast-fed  only. Unaware of the risks of using cow’s milk, Izzah’s parents provided this to  their daughter believing it would be beneficial to her. There were multiple interactions with a wide variety of different 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. On 6 August 2024, Izzah was seen in a Minor Injuries Unit and then  referred to paediatric colleagues in Royal Cornwall Hospital. At that time it is more likely than not that she had developed anaemia and this was the  cause of her pallor and distended abdomen. A urine dipstick confirmed a  urinary tract infection and antibiotics were prescribed. The anaemia was  not diagnosed. On 6 September 2024, Izzah was re-admitted into Royal Cornwall  Hospital. It was established that she was profoundly anaemic. She  needed to be treated by transfusion and this was undertaken. Izzah had a collapse and suffered cardiac arrests. She could not be resuscitated and  was verified deceased on 7 September 2024.

During the course of these inquests, the evidence has revealed matters  giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty  to report to you. The MATTERS OF CONCERN are as follows. I wanted to ensure that the authors of the Essential Guide to  feeding your Baby that I was told was being re-produced were aware of the facts of this case. I wanted them to reflect on whether the revised Guide needed to state that giving cow’s milk to an  infant under the age of one was not advised because it ran the risk of preventing the absorption of iron from other sources and causing anaemia.

In my opinion action should be taken to prevent future deaths and I  believe you [AND/OR your organisation] have the power to take such action.

You are under a duty to respond to this report within 56 days of the date  of this report, namely by 8/2/2026. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be  taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed.