Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0003, written 6 Jan 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Jan 2015 |
|---|---|
| Reference | 2015-0003 |
| Deceased | Carla London |
| Coroner | Andrew Walker |
| Coroner area | London (North) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Child Death (from 2015) |
| 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.
ep ag North London C Court, i ee.) Her Majesty’s Coroner for the 09Wood Steet ese 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 |S BEING SENT TO: Departinent of Health Richmond House 79 Whitehall London SWI1A 2NS 1 CORONER tam Andrew Walker, senior coroner, for the coroner area of Northern District of Greater London 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. | } On the 15 Day of April 2014 | opened an investigation touching the death of Carla London , 12 days old. The inquest concluded on the 21st November 2014. The conclusion of the inquest was "Natural Causes’, the medical case of death was 1a E Coli septicaemia 1b Extreme Prematurity 4 | CIRCUMSTANCES OF THE DEATH Carla was born on the 14" April 2011 weighing 970 gms in hospital. On the 20" April Carla was given a course of antibiotics for a suspected sepsis. The antibiotics were stopped on the 24" April 2011. During the afternoon of the 25" April 2011 Carla was noticed to be unwell by her mother and was reassured by a nurse. Carla was recognised to be unwell by the staff on the morning of the 26" April 2011 and rapidly deteriorated and died in hospital at 14.30 hrs on the same day. 3 | INVESTIGATION and INQUEST | i | | | Expert evidence heard at the inquest suggested that there should be NICE guidance on late onset sepsis in under 1500 gms babies and that and for research in to HeRO or other infection monitoring systems. 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. i | | i ee — Her Majesty’s Coroner for the RS Northern District of Greater London ma (Harrow, Brent, Barnet, Haringey and Enfield) The MATTERS OF CONCERN are as follows. — That coroner shares the concerns expressed by the independent expert that consideration should be given to NICE guidance on late onset sepsis in under 1500 gms babies and that and for research in to HeRO or other infection monitoring systems. 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 Monday 30" February 2015. |, 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 Persons;- Representatives 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 thd release or the publication of your response by the Chief Coroner. 6" Janiary
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 Dr Dan Poulter MP Parliamentary under Secretary of State for Health ae RECEIVED | Department 05 MAR 2015 sear Whitehall of Health swia 2NS Tel: 020 7210 4850 POCS 912385 Andrew Walker HM Coroner for the Northern District of Greater London North London Coroner’s Court 29 Wood Street Barnet ENS 4BE 3" March 2015 Dear Mr Walker, Thank you for your letter to the Department of Health about the death of Carla London. I am responding as the Minister with responsibility for Child Health and the National Institute for Health and Clinical Excellence (NICE). I was very sorry to read about baby Carla’s death and I would be grateful if you would pass my sincere condolences to her family. Your report details Carla’s very low birth weight and treatment for sepsis in April 2011. You also note that expert evidence heard at the inquest proposed that there should be NICE guidance on late onset sepsis in babies under 1500gms and suggested research into infection monitoring systems . The Government recognises the importance of starting well through early intervention and prevention and has included ‘low birth weight of term babies’ as an indicator of health improvement in Public Health Outcomes Framework for 2013-16. We have also made reducing infant mortality an area of improvement for the NHS in the NHS Outcomes Framework. In addition, the organisation Mothers and Babies - Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACE-UK), has been appointed to continue the national programme of work investigating maternal deaths, stillbirths and infant deaths. They aim to identify what went wrong and why and will make national recommendations on how care can be improved for all mothers and babies. The Royal College of Obstetricians and Gynecologists (RCOG) produced specific guidelines on bacterial sepsis during and following pregnancy in 2012 and in January 2015, the Department announced further measures to tackle sepsis, involving the NHS, government and national health bodies. Our aim is to make tackling sepsis as important to the NHS as C. difficile and MRSA, where rates have virtually halved since 2010. It is estimated that 11,000 lives and £160 million could be saved every year through better diagnosis and treatment. Plans include an audit of practice in every GP surgery in England by March 2015, and a new tool for GPs to diagnose sepsis among children under 5. New diagnosis and incentivised treatment goals for hospitals are also designed to help raise standards. Further information is attached for your convenience and available at: www.gov.uk/government/news/new-action-to-reduce-sepsis We have shared your report with the Centre for Clinical Practice at NICE, so that NICE can take your concerns about this case into account in the development of its guidance in this important area. NICE’s clinical guideline development process involves an assessment of the available evidence, and consultation with key stakeholders. NICE is currently developing a clinical guideline on sepsis which will cover the recognition, diagnosis and management of severe sepsis in people of all ages. NICE will decide whether this should include an assessment of the HeRo heart rate monitoring system and other such systems. NICE currently expects to publish its final guidance on this topic in July 2016. The new guideline is intended to complement existing NICE guidance on antibiotics for early- onset neonatal infection. This was published in 2012 and outlines best practice for preventing and treating sepsis in infants during the neonatal period. Further information is available at: www.nice.org.uk/guidance/indevelopment/gid-cgwave0686 Local maternity and neonatal care providers determine how best to deliver services in their area. In doing so we would always expect them to give due regard to NICE guidance. I hope that this information is helpful and I thank you for bringing the circumstances of Carla’s death to our attention. Best wishes, DR DAN POULTER
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