Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0089, written 25 Feb 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 25 Feb 2014 |
|---|---|
| Reference | 2014-0089 |
| Deceased | Andre Matei |
| Coroner | Andrew Walker |
| Coroner area | London (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.
i i Ga HON, 4, North London C Court, Her Majesty’s Coroner for the 29 Wood Steet Northern District of Greater London Barnet ENS 4BE (Harrow, Brent, Barnet, Haringey and Enfield) Telephone 0208 447 7680 Fax 0208 447 7689 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Department of Health Department of Health Richmond House 79 Whitehall London SW1A 2NS CORONER | am Andrew Walker, senior coroner, for the coroner area of Northern District of Greater London CORONER’S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. INVESTIGATION and INQUEST On the 6" January 2011 | opened an inquest touching the death of ,Andrei Ciprian Matei aged 65 minutes. The investigation concluded at the end of the inquest on the 4! December 2013. The conclusion of the inquest was “Narrative Conclusion”, the medical case of death was ;1a Peripartum asphixia , 2 Abnormal placental maturation. CIRCUMSTANCES OF THE DEATH On the 12"" December 2010 at 18.58 Andrei Ciprian Matei born in Hospital following an emergency caesarean section. Andrei was suffering with progressive intrapartum hypoxia that is likely to be related abnormal placental maturation. The decision to commence oxytocinon and to opt for forceps delivery rather than an emergency caesarean section delivery at 18.35 hrs were adverse factors that contributed to the development of the foetal hypoxia. There were concerns raised that the baby Matei’s mother, who had trouble speaking and understanding English, did not have an interpreter with her when taken to theatre There was a failure to follow the consultant plan and NICE Guidelines in not taking a further foetal blood sample which was likely to have been abnormal if taken at 18.09 There was a failure to pick up the abnormality in the CTG trace from 17.20 onwards which by 18.00 hrs was likely to have been pathological. It is likely that a significant hypoxic insult occurred at the time of foetal head rotation and the application of forceps. F Her Majesty’s Coroner for the * Northern District of Greater London (Harrow, Brent, Barnet, Haringey and Enfield) eo) a gy, fea A "a There was a lost opportunity between 18.09 hrs and 18 20 hrs for an emergency delivery which if taken is likely, depending on the method of delivery chosen, to have led to a greater chance of survival. 5 | 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) There was no national guidance on the role of interpreters during labour in particular when the interpreter is required in theatre. 6 | 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. 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by Thursday 1 May 2014. |, the 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. 8 | COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested parties The trust and solicitors representing the members of the family. lam 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 form. 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 coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 | 25" Fabra 201 ended 6" March 2014 | |
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_847908 SILA 2NS Tel: 020 7210 3000 Mr A Walker Mb-sofs@dh.gsi.gov.uk Senior Coroner North London Coroners Court 29 Wood Street Barnet ENS 4BE 29 APR oni Duy be web, Thank you for your letter following the inquest into the death of baby Andrei, Ciprian Matei. In your report you conclude that the medical cause of death was peripartum asphixia and abnormal placental maturation. Andrei Ciprian Matei was born in Barnet Hospital on the 12 December 2010 at 18.58 following an emergency caesarean section and was suffering from progressive intrapartum hypoxia, likely to be related to abnormal placental maturation. There was a decision to commence oxytocinon and to opt for forceps delivery rather than an emergency caesarean section delivery at 18.35 which you consider were adverse factors that contributed to the development of the foetal hypoxia. There were concerns that the baby’s mother, who had trouble speaking and understanding English, did not have an interpreter with her when taken to theatre. You point out failures to follow the consultant plan and NICE Guidelines in not taking a further foetal blood sample, which was likely to have been abnormal if taken at 18.09, and failure to pick up the abnormality in the CTG trace from 17.20 onwards, which by 18.00 hours was likely to have been pathological. You consider it likely that a significant hypoxic insult occurred at the time of foetal head rotation and the application of forceps. You report that there was a lost opportunity between 18.09 hours and 18.20 hours for an emergency delivery which could, depending on the method of delivery chosen, have led to a greater chance of survival. You therefore raise the following matter of concern: e There was no national guidance on the role of interpreters during labour in particular when the interpreter is required in theatre. I note firstly that the matter of concern you raise for my attention does not relate to failures around the medical care of mother and baby during labour and birth. These are issues that I agree should be properly addressed by Barnet and Chase Farm Hospital NHS Trust. I also note that Barnet and Chase Farm Hospital NHS Trust do provide interpreting services to meet the communication needs of patients and their families. They are able to access over 55 languages using the services of freelance interpreters or agencies, Details of how to book an interpreter in both normal hours and in emergency and out-of-hours is available on their website at the following address: hitp://www.bef.nhs.uk/for_patients/interpreting-services/index However, I cannot comment on why no interpreter was with baby Andrei’s mother when she was taken to theatre and advise that this is a matter best addressed by the Trust. I fully agree that the availability of interpreters when necessary for women giving birth is an important matter. Current National Institute for Clinical Excellence (NICE) guidelines on Antenatal Care advise that: “Information should be given in a form that is easy to understand and accessible to pregnant women with additional needs, such as physical, sensory or learning disabilities, and to pregnant women who do not speak or read English.” These Guidelines can be found at http://www.nice.org.uk/Guidance/CG62 The Royal College of Obstetricians and Gynaecologists (RCOG) also advise in their current Standards for Maternity Care (published 2008) that: “There should be provision for translation, interpreting, and advocacy services, based on the assessment of the needs of the local population.” The provision of such services is however decided, negotiated and commissioned locally by individual NHS and Foundation Trusts. In addition, a lack of suitable interpreters is one of the key themes running throughout the eighth report on Confidential Enquiries into Maternal Deaths (Saving Mothers’ Lives), published in 2011. dee Department of Health This report recommends that: “Commissioners and providers of maternity services should therefore ensure that professional and independent interpretation services are available in both primary- care and secondary-care settings, to ensure that all women can be confident that they can speak freely and in confidence to their maternity-care providers.” Although this is not in itself a national guideline, it is a widely distributed, influential and highly valued UK report. The full report can be found at: http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.2010.02847.x/pdf It is open to NICE to incorporate the recommendations of this report into future guidance. Although the guidance I have detailed does not, and in my view could not reasonably specify the exact roles of interpreters during labour or in theatre, NICE may wish to consider a review of their current guidelines in this respect. I will ensure that the matters you raise are brought to their attention for future consideration. I hope that this response is helpful and I am grateful to you for bringing the circumstances of baby Andrei’s death to my attention. ‘ur sr awrdy Jy JEREMY HUNT
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