Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0151, written 4 Apr 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Apr 2014 |
|---|---|
| Reference | 2014-0151 |
| Deceased | Eric Matthews |
| Coroner | R Brittain |
| Coroner area | Inner North London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | University College London Hospitals NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: (1) University College London Hospitals NHS Foundation Trust 1 CORONER I am R Brittain, Assistant Coroner for Inner North London 2 CORONER’S LEGAL POWERS I 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. 3 INVESTIGATION and INQUEST The investigation into the death of Eric Laser Matthews, aged 1 month, was commenced on 9 January 2014 and concluded at the end of the inquest on 2 April 2014. The conclusion of the inquest was narrative (Copy attached). 4 CIRCUMSTANCES OF THE DEATH Eric Matthews was born on 26 November 2013. He was discharged home after a course of antibiotics, which was required for presumed sepsis. Over the next month he was well and no further issues of concern arose. On 24 December 2013 his parents placed him in a ‘sling’ baby carrier in order to comfort him during a period of crying. He appeared to settle during a short walk, however, on their return home it was clear that Eric was not breathing. Resuscitation was started and the ambulance service called. After a period of approximately 39 minutes, sufficient circulation returned so that resuscitation could be stopped. Eric was ultimately transferred to Great Ormond Street Hospital where, despite further treatment, he was found to have suffered a significant hypoxic injury to his brain. Treatment was discontinued and he died on 1 January 2014. Evidence was provided by Paediatric Pathologist, that, on the balance of probabilities, the cause of the cardiac arrest was positional asphyxia. There was no evidence that the use of the sling was inappropriate or incorrect. In her evidence stated that there have been reported cases of infant deaths in similar circumstances, notably in the United States and Australia. She noted that , Perinatal Pathologist at UCLH, is currently collating reports of such cases in the UK, with a view to understanding this risk more thoroughly. Eric’s parents set out that they had no knowledge of the risk of positional asphyxia through use of a baby sling. Eric’s mother noted the valuable work undertaken by the 1 Lullaby Trust, with regard to the provision of information to parents relating to sleep positioning. She proposed that the Trust might be well placed to distribute similar information regarding sling use. 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 appears to be a body of evidence that positional asphyxia can occur through use of baby slings. However, knowledge of this risk appears to be limited at present to academic circles and has not been widely researched. (2) If there is currently sufficient evidence to raise this risk to parents, I am concerned that this information has not been publicised more widely. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe that the above information may be helpful to you, as it relates to the research you are undertaking on the risks posed by baby slings. It may be that you would wish to send details of your research to Eric's family and to organisations such as the Lullaby Trust, who may be able to publicise the risks posed, should this be appropriate now, or at any future point. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 30 May 2014. I, 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 I have sent a copy of my report to the Chief Coroner and Eric’s family. I 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 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 4 April 2014 Assistant Coroner R Brittain 2
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.
Histopathology Rockefeller Building University Street London WC1E 6JJ Telephone: 020 7679 6032 Chief Coroner St Pancras Coroners Court Camley Street London N1C 4PP 15.4.14 RE: PFD report - Eric Laser Matthews Dear Sir Although a couple of years ago I did investigate the possibility of doing a survey of ‘cot deaths’ in unusual scenarios such as slings and car seats, it did not prove feasible due to data protection and consent issues. These events are very rare: among perinatal pathologists nobody had seen more than one or two (verbal communications). Because they are all Coroner cases, the pathologists could not supply any further data without the consent of each individual coroner, often going back several years. The data exists, in the form of the child death reports, but these are not available as a research resource, and the data is held locally and not collated. Being so rare, any prospective collection of data would take many years, and further infants would die. The way forward may be for the coroners to liaise with clinicians who are working on sudden infant death (ideally via FSIDS), and release whatever data is available from existing child death reviews. Since the ‘back to sleep’ campaign, a subset of SUDI have been considered very likely to have been asphyxial – more investigation revealed that these are often associated with additional risk factors (e.g. sharing a sofa with a parent). What a review of deaths in slings and car seats might do is identify possible additional risk factors, such as the age of the baby or the design of the sling. Being so rare, no useful conclusions could be reached from the experience of one centre, even a very large one. UCL Hospitals is an NHS Trust incorporating the Eastman Dental Hospital, Elizabeth Garrett Anderson & Obstetric Hospital, The Heart Hospital, Hospital for Tropical Diseases, The Middlesex Hospital, National Hospital for Neurology & Neurosurgery, The Royal London Homoeopathic Hospital and University College Hospital. All we can say at present is that (very rarely) babies have died in carrying slings, and the information reaches the public via local inquest reports and the newspapers. Any progress would have to come from examination of child death review data. FSID is very interested in setting up a child death register for this reason, but is hampered by the same legal and consent issues as I was. There is clearly scope for further work, but this is very peripheral to my own professional interests and experience. I was trying to match people up, but was never in a position to run my own study. The chief executive at FSID was certainly interested, but I don’t know how much progress she has been able to make. I’m happy to talk on the phone about this if you want to discuss matters further. Yours faithfully Rosemary Scott FRCPath
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