Mandate a national safety protocol, to be known as "Rosie's Protocol", for the ventilation of newborn babies requiring cuffed endotracheal tube changes from an un cuffed Tube.

The protocol should require clinicians to safely reduce ventilator pressures before inflating a cuffed tube, to minimise the risk of sudden excessive airway pressure causing catastrophic lung injury. We believe this simple safety measure could help prevent avoidable deaths and serious harm to newborn babies and should become standard practice across the NHS.