Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0308, written 21 Feb 2013. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 Feb 2013 |
|---|---|
| Reference | 2013-0308 |
| Deceased | Jack William Partington |
| Coroner | Lisa Hashmi |
| Coroner area | Manchester North |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Pennine Acute Hospitals NHS Trust 2. Department of Health CORONER | am Lisa Hashmi, Assistant Coroner for the coroner area of Manchester North CORONER’S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroner’s and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. INVESTIGATION and INQUEST On 01/12/2011 the Senior Coroner commenced an investigation into the death of Jack William PARTINGTON, then aged 1 day. The investigation was concluded at the end of the inquest on 12/11/2013. The conclusion of the inquest was that Jack Partington developed Respiratory Distress Syndrome that necessitated management by way of nasal continuous positive airway pressure ventilation (CPAP). At 3:20 on the 26" November 2011, Jack developed a pneumothorax that was treated by way of drainage and intubation. He was given Atracuriam to facilitate the ventilatory process and treatment. Despite intubation, ventilation could not be achieved. Consequent to this, Jack’s heart beat weakened, became ineffective and stopped. Jack died at 05:12 on the 26" November 2011. The medical cause of death being: 1a) Hypoxia 1b) Insufficient ventilation of the lungs consequent upon the prescription of Atracuriam and insufficient artificial ventilation 1c) Respiratory Distress Syndrome CIRCUMSTANCES OF DEATH Jack Partington was born by way of a pre-planned lower segment caesarean section at 09:28 on the 25" November 2011. He cried almost immediately but within minutes of his birth stopped breathing. Neonatal resuscitation was commenced and was successful. Jack was taken to the special care baby unit (high dependency) for further treatment and monitoring. This treatment included nasal continuous positive pressure ventilation (nCPAP). Whilst he remained tachypnoeic overall, his other physiological parameters were satisfactory. At around 23:35 the nursing staff decided to take jack off ventilation for a trial period. This decision was supported by the duty paediatric Registrar when she reviewed Jack in the early hours of the 26" November. Initially he did well but he developed a requirement for oxygen and was therefore put back on nCPAP. By 3:20 his oxygen requirement and ‘grunting’ had increased. He was reviewed by the Registrar at around 3:45 and a diagnosis of pneumothroax was made. Oxygen therapy was put to 87% and the nCPAP pressure reduced to 2. The paediatric Consultant was called to attend, arriving at around 04:05. The pneumothorax was successfully ‘tapped’ by the Registrar whilst the Consultant cannulated a vein. The planned treatrnent was to intubate, ventilate and insert a chest drain (further treatment for the pneumothorax). In order to facilitate intubation, Atracuriam (a muscle paralysing agent) was administered by bolus dose. Jack’s vital signs deteriorated. intubation was attempted by the Registrar but was unsuccessful. The Consultant immediately took over, inserted the ET tube and was content that it was correctly sited in the trachea. Jack’s observations continued to plummet and the Consultant therefore extubated and reintubated. Again, he was satisfied that the tube was sited correctly. Advanced neonatal resuscitation was commenced, including the administration/introduction of the drugs Atropine and Adrenaline and cardiac massage. Jack’s oxygen saturation and heart rate continued to drop. He died at 05:12 on the 26" November 2011. CORONER’S CONCERNS During the course of the inquest the evidence 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) That there was no 1:1 neonatal nurse/cotside ‘handover’ at shift change, no individualised neonatal nursing care plan in use and no routine checks of medical records for new neonatal admissions. 2) Nursing staff, rather than the multi-disciplinary team plus parents, took treatment/change of treatment decisions in isolation and without consulting all available information (such as medical records etc.) 3) That disposable exhaled carbon dioxide detectors (ET CO2) were not routinely used on the NNU (as an adjunct) and that they are not currently/routinely used in many NNUs throughout the country. 4) There are no national standardised policies, protocols or guidance on the management and administration of paralysing agents to neonates in need of intubation and/or the management of ventilation in neonates. 5) No single individual within the neonatal (resuscitation) team was allocated to oversee and monitor the ventilatory pressure dial following intubation. The dial in question was situated on the side of the incubator/cot, out of the direct line of sight of the clinician controlling the airway/ventilatory process. ACTION SHOULD BE TAKEN in my opinion action should be taken to prevent future deaths and | believe you (AND/OR your organisation) have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely the 45 January 2014. I, the Assistant 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following interested Persons: Mr and vrs via their legal representatives). | am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary from. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me the Assistant Coroner at the time of your response, about the release or the publication of your response by the Chief Coroner. 21 November 2013. Signed eo Q. Yesstnas )
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
From the Rt Hon Jeremy Hunt MP Secretary of State for Health Department | of Health Richmond House 79 Whitehall London POCI_824991 SWIA 2NS Tel: 020 7210 3000 Ms L Hashmi Mb-sofs@dh.gsi.gav.uk Assistant Coroner HM Coroner’s Court The Phoenix Centre Church Street Heywood 1 4 JAN 2044 OL10 1LR Dew Ma. faslan’, Thank you for your letter following the inquest into the death of Jack William Partington. In your report you state that Jack died from hypoxia; insufficient ventilation of the lungs consequent upon the prescription of Atracuriam and insufficient artificial ventilation; and respiratory distress syndrome. You raise the following concerns about the nursing and medical care of Jack: e a lack of 1:1 neonatal nurse handover at shift change, individualised neonatal care nursing plan and routine checks of medical records for new neonatal admissions e nursing staff took treatment decisions in isolation and without consulting all available information e disposable exhaled carbon dioxide detectors were not routinely used on the Neonatal Unit (NNU) and are not currently routinely used in many NNUs throughout the country e no national standardised policies or guidance on the management and administration of paralysing agents to neonates in need of intubation or management of ventilation in neonates e No single individual was allocated to oversee and monitor the ventilator pressure dial following intubation TI note that you have sent a Regulation 28 report to the local NHS Trust for its response. I believe that the issues concerning staffing, staff training, governance and clinical issues are local issues that should properly be addressed by the Trust. NHS England is responsible for commissioning neonatal critical care services and has issued a standard contract for these services, which was adopted from 1 October 2013. In line with the contract, services should ensure robust clinical governance arrangements are in place. Services should also ensure there are robust monitoring and reporting arrangements in accordance with performance requirements and demonstrate evidence of continuing improvement of quality and responsiveness year on year through evaluation and audit. Guidance on the use of carbon dioxide detectors and the management and administration of paralysing agents to neonates in need of intubation should already be covered in the care guidance of every neonatal service. We do not therefore believe issuing duplicate guidance would be valuable. The Resuscitation Council (UK) has issued updated guidance on new-born life support, which recommends detection of exhaled carbon dioxide in addition to clinical assessment as the most reliable method to confirm placement of a tracheal tube in neonates with a spontaneous circulation. We have been advised by NHS England that carbon dioxide monitors are being used increasingly in neonatal units. However, their use in individual cases is a matter for the clinical judgement of the health professionals involved. The use of muscle relaxants is common practice in Neonatal Intensive Care Units as it is recognised good practice to give muscle relaxants for intubation together with pain relief. I will ensure that this case is notified to the British Association of Perinatal Medicine. In this way, the issues of concern will be brought to the attention of other neonatal teams throughout the country via the Association’s quality care process. I hope that this response is helpful and I am grateful to you for bringing the circumstances of Jack’s death to my attention. “Wr shawls Fy LA JEREMY HUNT
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