Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0343, written 25 Jul 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 Jul 2014 |
|---|---|
| Reference | 2014-0343 |
| Deceased | Nathan Healer |
| Coroner | Derek Winter |
| Coroner area | Sunderland |
| 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.
coe Derek Winter Senior Coroner for the City of Sunderland REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Rt Hon Jeremy Hunt Secretary of State for Health Department of Health Richmond House 79 Whitehall London SW1A 2NS CORONER 1am Derek Winter, Senior Coroner for the City of Sunderland 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. http://www. legislation.gov. uk/ukpga/2009/25/schedule/5/paragraph/7 http://www. legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 06/02/2014 | commenced an investigation into the death of Nathan James Healer, at 2 days of age. Following his death on 05/02/2014, the investigation concluded at the end of the inquest on 24/07/2014. The conclusion of the Inquest was “Although the severity of Nathan's condition was not appreciated and he was not given the opportunity of a more timely blood glucose test he died of a natural cause”. Medical cause of death was confirmed as: ta Neonatal Encephalopathy and Intraventricular Haemorrhage (Grade 4); 2 Poorly Controlled Gestational Diabetes. CIRCUMSTANCES OF THE DEATH Nathan’s mother had gestational diabetes and during the pregnancy had very regular contact with medical professionals. Nathan was born on 03/02/2014 at 0718 hours without complications and his Apgar scores were good. However his colour was not all that it ought to have been, he was cold and was slow to feed. It was also reported that his eyes were bulgy, he had jittering arms and excessive startle reflux. When his Biood Glucose was measured for the first time at almost 5 hours from his birth it was 0.2 mmol/L. Despite intervention at this point Nathan died on 05/02/2014. 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. — | was made aware of: - a) the 2008 NICE Clinical Guidance 63 “Diabetes in Pregnancy” which in essence recommended a pre 2™ Feed Blood Glucose test at between 2-4 hours; b) the hospital Guidance for “Hypothermia in the newborn Infant” 2014; c) the hospital Guidance for “Prevention, detection and management of hypoglycaemia in the newborn 2012 (Blood glucose test at around 4 hours). Although the severity of Nathans’s condition was not appreciated and he was not given the opportunity of a more timely blood glucose test | heard evidence that although new guidance from NICE is in contemplation it has not yet been finalised. If that is the case then it would be helpful to know what stage this is at and whether any steps can be taken to expedite it’s production. If no new guidance is in contemplation then it may be an opportune moment to revisit the guidance in any event. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you 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 by 22 September 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. COPIES and PUBLICATION ! have sent a copy of my report to the Chief Coroner and to the following Interested Persons: - ~ Family and their Solicitors - City Hospitals Sunderland NHS Foundation Trust and their Solicitors ~ Care Quality Commission 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. Dated this 25th.day of July 2014 Signature [ Senior Coroner for the City of Sunderland
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.
i i Y From Dr Dan Poulter MP Parliamentary Under Secretary of State for Health Department seehponai of Health O79 Wtenat London POCS 887782 SWIA 2NS ro Mr D Winter Senior Coroner Civic Centre 03 SEP 2014 Bourdon Road —— Sunderland os SR2 7DN 08 sep oo 5 1 ee one ee Thank you for your letter following the inquest into the death of Nathan Healer. In your report you conclude that the medical cause of death was Neonatal Encephalopathy and Intraventricular Haemorrhage (Grade 4), and Poorly Controlled Gestational Diabetes. Nathan’s mother had gestational diabetes, and kept regular contact with medical professionals throughout her pregnancy. You noted that Nathan was born on 3“ February 2014 at 7.18am without complications, and his APGAR test results were good. However, his colour was not all that it ought to have been, and he was cold and slow to feed. It was also reported that his eyes were bulgy, he had jittering arms and excessive startle reflux. You further noted that Nathan’s blood glucose was measured for the first time at almost five hours from his birth, registering at 0.2mmol/L. Although intervention began at this point, Nathan died two days later on 5" February 2014. You raise the following matters of concern: o The 2008 National Institute for Health and Clinical Excellence (NICE) Guideline CG63 ‘Diabetes in Pregnancy’ in essence recommended a pre 2" feed blood glucose test at between 2-4 hours. © Although the severity of Nathan’s condition was not appreciated, and he was not given the opportunity of a more timely blood glucose test, you understand that new guidance from NICE is in contemplation but has not yet been finalised, and would like to know what stage this is at and whether it can be expedited. We understand that NICE Guideline CG63 is currently under review. Draft guidance is due to go out for consultation on 11" September 2014, ending 23™ October 2014. The finalised guidance is expected to be published in February 2015. Further details about this work can be accessed on the NICE website at the following address: http://www.nice.org uk/guidance/indevelopment/GID-CGWaveR107 Given the imminence of the new guidance, advice from Departmental policy officials is that there is no scope for this process to be expedited. However, as NICE is an independent body, I advise you contact it directly with any further questions you may have about the review of this guidance. I hope that this response is helpful and I am grateful to you for bringing the circumstances of Nathan’s death to my attention. beh odes, DR DAN POULTER
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