Izzah Ali

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. 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. 1)  A theme that emerged during the evidence was the repeated  reference to Izzah being ‘bottle-fed’ without further inquiry. In this country, bottle-fed infers ‘formula-fed’ but it is a presumption and in this case it was a wrongly assumed presumption. As one witness  observed: ‘bottle-fed’ does not explain what was in the bottle. It  could be a formula preparation, equally, it could be expressed  breast milk. In this case, it was cow’s milk but until Izzah’s last  admission into hospital no healthcare professional established that crucial fact. That reflects a failure to recognise that ‘bottle-fed’ is an incomplete description and requires an additional question of what is in the  bottle. It also reflects a lack of appreciation around different cultural  practices: while it may be assumed that cow’s milk would not be  given to an infant under one in this country, it does not  automatically follow that the same is true in other countries, for  example, Pakistan. There was, in my judgment, an element of  assumption made here which could alternatively be described as a lack of professional curiosity. A second concern that emerged was that during both ante- and post-natal visits to a woman who did not speak English, no  interpreter was involved, contrary to guidance.

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. It is right that I acknowledge significant steps have already been taken by  some of the recipients of this report. In particular, I note the Enhanced Care Pathway now introduced at RCHT. Nevertheless, I considered the  learning that came out from this inquest to be so fundamental and of such wide application that I wanted to ensure it reached all HCPs in the county.