Promote standardisation of training and spreading of best practice, including competencies, and regular updates.

Use simulation training for preparing staff and carers for emergencies such as an unplanned tracheostomy change.

Use existing resources18 to ensure training for parents is consistently good.

Ensure correct spare equipment is available and that families know who to call for technical support.

Ensure incidents are reported to manufacturers and that design solutions are implemented.

Set national minimum standards in care packages to ensure parents are confident in the care their child is receiving.

Make reporting incidents easier for families.

Set clear national standards across the patient pathway to improve coordination and communication between services.

Ensure commissioners and care providers have high-quality systems in place to train and support those providing high-risk care.