Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0351, written 31 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 | 31 Jul 2014 |
|---|---|
| Reference | 2014-0351 |
| Deceased | Antonio Allen |
| Coroner | John Pollard |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Central Manchester University Hospitals NHS Foundation Trust |
| 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Chief Executive Officer, Central Manchester NHS Foundation Trust. 1 | CORONER | am John Pollard, senior coroner, for the coroner area of South Manchester 2 | 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 3 | INVESTIGATION and INQUEST On 22™ July 2013 | commenced an investigation into the death of Antonio Jerome Allen dob 17" June 2013. The investigation concluded on the 18" June 2014 and the conclusion was one of Natural Causes. The medical cause of death was 1a Intra- abdominal Haemorrhage 1b Sub-capsular Haematoma (Liver and Spleen) 4 | CIRCUMSTANCES OF THE DEATH On the 26" June 2013 at 07.40 hours, Antonio Allen was admitted to Trafford General Hospital in cardiac arrest with no respiratory effort and no palpable pulse. His mother had breast fed him at 01.00 hours and then found him unresponsive at 06.45 hours. Despite the best efforts of the ambulance and Emergency Department personnel, he could not be revived. 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. — It had been arranged that this was to be a home birth and the midwives based at Lostock Medical Centre were aware of this. His expected date of delivery was the 15" June but in fact he was born on the 17" June. The mother and grandmother of Antonio tried on four separate occasions to call out a midwife to attend the birth but in fact the delivery had to be carried out by the grandmother and a neighbour. Two midwives eventually arrived, checked the baby and said all was well although he was a bit ‘puffy’ because it was a ‘quick birth’. IF A HOME BIRTH IS BOOKED AND EXPECTED OR INDEED OVERDUE, IT SHOULD NOT BE THE CASE THAT THE MIDWIVES ARE NOT CONTACTABLE, NOR THAT THEY ARRIVE AFTER THE BIRTH HAS OCCURRED. 6 | 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 3 duty to respond to this report within 56 days of the date of this report, namely by 25" 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 co ‘0 the Chief Coroner and to the following Interested Persons namel mother). ! 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 tepresentations to me, the coroner, at the time of your response, about the eae r the publication of your response by the Chief Coroner. 31st July 2014 John Pollard,Senior Coroner SS
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.
Central Manchester University Hospitals NHS NHS Foundation Trust Room 217 Np sated Slto/te Medical Directors Office LEZ Loy Trust Headquarters Manchester Royal Infirmary Oxford Road Manchester, M13 9WL 24" September 2014 Mr J S Pollard HM Coroner Manchester South Coroner's Court 1 Mount Tabor Street Stockport SK1 3AG Dear Mr Pollard Re: Antonio Jerome ALLEN (Deceased) Thank you for your letter to Sir Michael Deegan of 31° July 2014, he has asked me to reply on his behalf. | instructed the clinical team to review the case and have set out the answers to the points noted in the Regulation 28 notification below. The priority of the maternity directorate is to provide safe and high quality maternity care for all women and their partners regardless of their choice of place of birth. Options for place of birth are discussed fully with the woman and her partner/family to enable women to make an informed choice. At the booking consultation a full medical, surgical, obstetric and social history is taken to support women in their decision by discussing the risks and benefits of choices available. Women are also given an information leaflet to enable them to discuss their options further with their family. Maternity staffing is managed to ensure that the community midwifery team can respond to requests from women at any time of the day or night when a home birth is planned in order to ensure women and their family receive optimal care and support. On the 17th June 2013 at approximately 04:20 hours community midwife [a was informed by a fellow midwife, working on the midwifery led unit, of the imminent delivery at EEE home address. Midwife [iiiJimmediately colle ergency equipment and attended Patient A’s home. On arrival at 04:44 hours was on the kitchen floor with her baby placed on her abdomen (skin to skin). Midwife performed a full risk assessment once and her baby were comfortable and settled and made the decision that it was safe for both to remain at home. The mother of [EEE informed Midwife [that she had telephoned the dedicated telephone number from approximately 04:00 on four occasions until approximately (04:20 / 04:30 hours) but her call was not answered. (All women who are booked for a planned home birth are given a dedicated number to contact. This telephone line is normally in operation 24 pours) mother reported that she then called the Triage department who transferred ner call to the community midwifery team. ry Incorporating:- 2S So, = 7 %y INVESTORS Manchester Royal Eye Hospital ¢ Manchester Royal infirmary + Royal Manchester Children’s Hospital 4 Saint Mary’s Hospital ¢ Trafford Hospitals + University Dental Hospital of Manchester ne IN PEOPLE Community Services “Csy x bam Central Manchester University Hospitals NHS) NHS Foundation Trust Following her return to the hospital Midwife HB alettec the radio telephone administration staff of the difficulties experienced by the family. On investigation it was identified that there had been a known fault on the telephone line earlier in the day but this had been resolved by the engineers. There is a process in place to ensure that the essential telephone lines are checked at the beginning of each shift; it was apparent that the administrator did not follow the process for checking the phone line at commencement of their shift so was unaware that the fault had reoccurred. On being informed by Midwife [J of the unanswered phone calls the administrator notified switchboard of the fault on the line and immediate action was taken to reconnect the telephone line. To ensure that this never happens again women are now given two telephone numbers to call in case one line is busy or faulty. A standard operating procedure in place to check that the essential telephone lines are fully functioning. Yours sincerely = —_ cc. FY Clinical Head of Division, Saint Mary’s Hospital GEE Divisional Director, Saint Mary's Hospital Zo 7a, Incorporating:- + Abo, ‘y INVESTORS Manchester Royal Eye Hospital ¢ Manchester Royal Infirmary # Royal Manchester Children’s Hospital ye Hosp y Pi is ¢ University Dental Hospital of Manchester ROS, a ; “fess Saint Mary’s Hospital ¢ Trafford Hospital: © _a IN PEOPLE Community Services “Osa?
See every Prevention of Future Deaths report matching Central Manchester University Hospitals NHS Foundation Trust, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.