Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0569, written 28 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 | 28 Jul 2014 |
|---|---|
| Reference | 2014-0569 |
| Deceased | Hope Evans |
| Coroner | Colin Phillips |
| Coroner area | Swansea Neath & Port Talbot |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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)
NOTE: This form is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
GE (Seri0r Medical officer, Maternal and Child Health) Welsh
Government.
l
CORONER
| am Golin Phillips, acting Senior Coroner, for the coroner area of SWANSEA NEATH &
PORT TALBOT
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.
2
0
VINVESTIGATION and INQUEST
On 15 November 2011 | commenced an investigation into the death of Hope Erin Evans.
The investigation concluded at the end of the inquest on 16 July 2014.
The medical cause of death is
ta Sepsis
1b ESBL E. coli in a premature baby
The conclusion of the inquest as how Hope came to her death is a narrative one and is
as follows:-
Hope died from sepsis contributed to by the ESBL E. coli which was contracted in
hospital after being born prematurely at 26 weeks. The source of the ESBL.E. coli is
likely to have been from another baby but the means of transfer is unknown.
+
CIRCUMSTANCES OF THE DEATH
The deceased was Hope Erin Evans and she died at 1.00 a.m. on 4 November 20114 at
Singleton Hospital Sketty Swansea. Tests confirmed that baby Hope and baby A1 and
baby A2 to have had the same strain of the ESBL E.coli. The outbreak management
group therefore concluded that the ESBL E.coli was probably transmitted between the
babies.
Mother A had received private IVF treatment abroad and received a twin pregnancy.
Mother A contracted ESB L E. coli although it is unclear how this was contracted. This
was reflected as a positive ESB L E. coli result and identified in Mother A's medical
notes from abroad which she had in her possession and declared them several days
after the outbreak.
Mother A was transferred from Prince Charles’s Hospital Merthyr to Singleton Hospital
Swansea due to premature labour and spontaneous rupture of membranes. Where there
are transfers between hospitals the Atl Wales Inter Hospital Transfer documentation
should be completed and sent with the women’s documentation to the receiving
hospital. This documentation has the potential to alert staff to risk factors although there
is no specific question relating to women having treatment abroad or having contracted
an alert organism. There is no evidence to suggest that this document was completed
and sent to Singleton Hospital nor was it requested by anyone at Singleton.
All three babies were delivered by Caesarean section on the same day (31st of October
2011) in the same theatre and were transported to the ITU in the Neonatal ward.
The babies were placed in cots in close proximity to each other in the ITU unit. At the
time the neonatal unit TU environment was poor with evidence of dated facilities. The
number of sinks within the area was inadequate for the number of cots in use at the time
of the outbreak. The spacing of cots did not meet current standard
The Neonatal ward has undergone substantial refurbishment to ensure more space
around the cots and improved hand washing facilities.
Screening for ESPN L E. coli is not recommended routinely in UK neonatal units except
under outbreak conditions. The ESBL E. coli infection is becoming more frequent
worldwide due to injudicious antibiotic use in the community and particularly in India and
other countries where antibiotics are freely available over the counter. However recently
pockets of infection are arising in this country.
It was not until around midday on 3 November that the microbiologist informed the Neo
Natal unit of the results of mothers A's cultures (taken on the 29 October while mother A
was at Prince Charles Hospital) showing ESBL E. coli.
=]
COROWNER’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. —
41. {have concerns that important patient history was not captured by the admitting
hospital and passed to the receiving hospital. Mother A had received IVF
treatment in India and had there acquired the ESB L E. coli. This important
information was recorded in her medical notes which were with her. If the
receiving hospital was aware of this then certainly the treatment of the twins
would have been different and barrier nursing would have been implemented.
2. The All Wales Inter Hospital Transfer documentation was not completed and
revision of the documentation should be considered.
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 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
— and to the LOCAL SAFEGUARDING BOARD.
| 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.
28 July 2014 a Zz. [SIGNED BY CORONER]
Lt
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