Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0056, written 16 Feb 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Feb 2015 |
|---|---|
| Reference | 2015-0056 |
| Deceased | Mohammed Yousaf |
| Coroner | Lisa Hashmi |
| Coroner area | Manchester North |
| Category | Child Death (from 2015) · Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Pennine Acute Hospitals NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Department of Health (concern 1) 2. Royal College of Obstetricians & Gynaecologists (concern 1) 3. Pennine Acute Hospitals NHS Trust (concern 2) I CORONER I am Ms L J Hashmi, Area Coroner for the Coroner area of Manchester North 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 ofthe Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On the 1th1 February 2015 I commenced an investigation into the death of infant Rahat Qayyum (otherwise known as Mohammed Rahat Yousaf). 4 CIRCUMSTANCES OF DEATH On the 5” July 2013, the deceased’s mother was admitted for planned induction of post- term labour. At around 15:50 hours, a CTG demonstrated anomalies. The midwife sought a medical review. The initial CTG demonstrated recovery however by 20:50 hours, a further trace showed evidence of a more marked anomaly. The significance of this CTG was not fully recognised. At 22:00 hours doctors made the decision to proceed to emergency caesarean section. As a consequence, the deceased’s motherwas transferred to the labourward at around 22:20. At 22:48 a further examination was carried out by a doctor during the course of which an artificial rupture of membranes was performed. Tenacious, fresh meconium was noted within the liquor. The deceased’s mother was transferred to theatre at 22:53 with baby being delivered in a very poor condition at around 23:42. Neonatal resuscitation was commenced immediately and thereafter, the deceased was transferred to the NICU. Over the course of the next few days, tests showed that the deceased was suffering from electrocerebral silence, meconium aspiration syndrome, seizures, hypoxic cardiomyopathy and presumed sepsis. The deceased’s condition continued to deteriorate and he died on the 1th9 July 2013 from hypoxic ischaemic encephalopathy due to or as a consequence of perinatal asphyxia. During the course of the treatment and care provided, an official Interpreter was not summoned or utilised. 5 CORONER’S CONCERNS During the course ofthe 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 reportto you. The MATTERS OF CONCERN are as follows:- During the course ofthe inquest the following concerns were identified: 1. Whilst Pennine Acute Hospitals NHS Trust has now established its own local guidelines based upon recent research conducted in Bristol, there are no national guidelines on how to interpret and/or classify antenatal (as opposed to intra-partum) CTG tracings. 2. The dissemination, application and applicability ofthe Trust’s Interpreting Policy, by its staff, in force at the material time (with particular regard to the obtaining of informed consent). 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe each of you respectively have the powerto 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 the l4 April 2015. 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 senta copy ofmy reportto the ChiefCoronerand to the following Interested Persons namely: The Deceased’s family I am also undera duty to send the ChiefCoroner a copy ofyour response. The Chief Coroner may publish either or both in a complete or redacted or summary from. 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 bythe ChiefCoroner. Date: February 2015
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