Isabella Hope Hill

Liverpool Women’s NHS)

NHS Foundation Trust

Crown Street

RECEIVED |

Tel No: 0151 702 4216

FaxNo:  _0151 702 4432 wie
E-mail: 18 DEC 2013

Our Ref: Tel: 0151 708 9988
Your Ref: H. M. CORONER www. |wh.nhs.uk

Date: 18" December 2013 on
Ss Oy

Mr. A Wilson Ws C)

Assistant Coroner for the City of Liverpool

St. George’s Hall

St. George’s Place

Liverpool

L1 1JJ

INVESTOR IN PEOPLE,

Dear Mr. Wilson,

Re: Isabella Hope Hill
Report to Prevent Future Deaths

Further to the Inquest into the death of Baby Isabella Hope Hill which commenced on 27"
July and concluded on 11™ October 2013. | give below, my response to your request
pursuant to Paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009 and
Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. My response
identifies the actions we have taken to prevent future deaths and, where possible, | have
included our timescales for implementation of those changes.

Background

Isabella Hope Hill was born on 10" July 2013 at 26 weeks gestation. She was admitted to
the Trust's Neonatal Intensive Care Unit (NICU) due to her prematurity. As part of her
treatment and care, Isabella had an umbilical venous catheter (UVC) inserted through which
she received her nutrition and other required intravenous fluids; blood products and
medication. The UVC was inserted and then withdrawn by 1 cm following review of her
abdominal x-ray. According to the Unit's Guidelines, Isabella should have been re-x-rayed
after the UVC was re-positioned as the tip of the UVC had originally been located in her
heart. At 18:00 hours on 10" July 2013, during the medical staff handover, it was noted,
when reviewing her earlier x-ray, that the UVC was still positioned too high despite being
withdrawn by 1cm. It was noted that there should be a repeat x-ray the following morning.
This x-ray was not, however, performed on 11" July 2013.

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Po Liverpool Women's

Liverpool Women’s NHS)

NHS Foundation Trust

Isabella initially remained well until she started to show signs of deterioration on 12" July
with bradycardias (slowing down of her heart rate) and desaturations (a drop in the oxygen
levels in her blood). On the afternoon of 13" July it was noted that her oxygen
requirements were increasing, she was having a number of desaturations and, that the
bradycardias now required intervention. She subsequently required ventilation at 18:00
hours on 13" July 2013. Post intubation, her abdomen was noted to be shiny and distended
but soft. Her feeds were therefore stopped as a precaution. An x-ray of her abdomen was
taken at 18:41 hours was taken and a provisional diagnosis of necrotising enterocolitis was
made. The on-call consultant neonatologist was contacted at approximately 19:00 hours
home and she was commenced on antibiotics. He was contacted again at approximately
23:00 hours and up-dated about her worsening abdominal distension. He advised that, as a
precaution, Isabella be treated conservatively and metronidazole an additional antibiotic was
added to her treatment regime.

In the early hours of 14" July, it was noted that Isabella’s abdomen was looking more
distended and a repeat abdominal x-ray was performed. Her blood gases remained
unsatisfactory requiring correction and at 02:45 hours on 14" July 2013, Isabella had a
sudden collapse requiring cardiac massage and re-intubation. The On-call consultant
neonatologist was called in from home and he arrived at 03:15 hours. He reviewed the
earlier x-ray and noted that the UVC was mal-positioned. All fluids were therefore stopped
and an abdominal tap was performed which drained approximately 30 mls of intravenous
nutritional fluids. An abdominal drain was inserted. Following this procedure, her
distended abdomen; saturations; heart rate and colour were visibly improved and it was
possible to reduce her level of ventilation. The Consultant commenced an Adverse Clinical
Event Investigation. Although Isabella’s condition improved, she remained poorly but stable
throughout 16" July 2013. Sadly, however, on the morning of 17" July, Isabella had an
acute deterioration that required aggressive resuscitation. This resulted in her heart rate
and saturations improving and her condition stabilised for approximately 20 -30 minutes
after which she had a further collapse. {3M were involved in the decision to
cease resuscitation and Isabella was certified dead at 10:35 hours on 17" July 2013. HM
Coroner for the City of Liverpool and the Liverpool Clinical Commissioning Group were
notified of the death.

The previously commenced Adverse Clinical Event investigation was escalated to a Serious
Incident Investigation and a multidisciplinary panel met to review the death on two separate
occasions. The Review Panel concluded that the root cause of Isabella’s death was the
inadvertent infusion of fluid into her peritoneal cavity.

An Action Plan was generated following the Trust’s Serious Incident Review process and
has been populated by recommendations and learning points from the Review. The Action
Plan is being progressed by the neonatal Clinical Governance and Risk Leads and progress
will be monitored by the Neonatal Executive Board, the Trust Board and by Liverpool
Clinical Commissioning group until all actions have been completed. All actions have a
designated lead and timeframes for completion.

The investigation highlighted the following areas where changes were required to prevent

future similar incidents:
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2 Liverpool Women’s €

Liverpool Women’s NHS)

NHS Foundation Trust

What we identified: and what we have done to implement necessary changes:

1:

There was a lack of awareness of line position and the need to remove the UVC on

13th July

at 18.49 hours. There was also a failure to recognise the significance of an

unexpected clinical deterioration with abdominal distension in a baby with a central
venous catheter in-situ.

What we have done to implement necessary changes:

a)

c

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2.
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vi.

e)

f)

A review of the method of fixing UVCs and documentation regarding line
positioning commenced in November 2013 to consider whether a more
secure way could be identified to prevent migration of UVCs. Practice
comparisons with other level 3 neonatal units and literature searches have
confirmed LWH's practice to be consistent with practice in other neonatal
units.
The neonatal guideline in respect of UVCs was revised immediately and
now includes the following statement: ‘Any sudden or unexpected
deterioration in a baby with a central venous catheter in-situ should always
prompt an urgent assessment of the position of the catheter tip. Serious
complications such as pericardial effusion/cardiac tamponade or infusion of
fluid into the pleural or peritoneal cavities should be excluded by x-ray or
ultrasound.’ The revised guideline was re-launched with the new cohort of
junior medical trainees who commenced their placement in August 2013.
Further guideline work is planned to include the potential consequences of
using a central venous catheter that is not in an optimal position.
Details of possible complications of misplaced UVCs and learning points
from this case were disseminated to staff during August, September,
October and November 2013 as follows:

The Neonatal Great Day (an internal day of information sharing for

neonatal staff);

Mandatory multidisciplinary educational sessions;

Lesson of the Week which is disseminated to all medical and nursing

staff at the beginning of all medical and nursing staff shift changes;

This case was included in the August medical staff induction

programme and will be incorporated into all future medical staff

inductions;

Learning points are frequently reiterated at weekly staff Risk Huddles;
Lessons learned were discussed at the Cheshire and Mersey Neonatal

Network Meeting on 2" December 2013 and will be shared at the next
British Association of Perinatal Medicine meeting on 31% January 2014.

A prospective audit around compliance against revised guideline is in

progress,

Individual feedback to all staff involved in the event has C
Liverpool Women’s €

taken place and where necessary the educational

Liverpool Women’s INHS|

NHS Foundation Trust

supervisors of individual trainees have been informed of the event and their
trainees involvement.

2 We did not communicate the need for, or perform an x-ray on 10" July 2013
after repositioning the 2" UVC:

What we have done to implement necessary changes:

a) This issue has been addressed through enhanced local education for staff on
the Neonatal Unit in respect of the content of the revised guideline;

b) The current Service Level Agreement (SLA) for Radiology with an external
provider has been reviewed and clarified and now confirms that all required x-
rays on neonatal patients will be performed within 60 minutes of receipt of a
request, 24hrs per day and 7 days per week.

3 Medical Staff did not routinely complete the Task List on the electronic patient
administration system (Badger)

What we have done to implement necessary changes:

a) The Medical Staff Task List on the electronic patient administration system
(Badger) was not being used widely by all grades of medical staff or Advanced
Neonatal Nurse Practitioners and additional education sessions and Lessons
of the Week are planned to raise awareness and increase its use at handover
times.

| attach a copy of the Final Serious Incident Investigation Report and up-dated action plan
for your attention.

Please do not hesitate to contact me for clarification of any of the issues raised above or if
you require any further information.

Yours sincerely

Kathy Ther Wein

Kathryn Thomson
Chief Executive

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4 Liverpool Women’s C