Thor Dalhaug

08 may mr

Caring for Yow United Lincolnshire Hospitals A'774

NHS Trust

Trust Headquarters
Lincoln County Hospital
Greetwell Road

Lincoln

LN2 5QY

Tel:

e.mail:

Mr S P G Fisher

HM Coroner for Central Lincolnshire
Lindum House, 10 Queen Street
Spilsby

Lincolnshire

PE23 5JE

7 May 2015

Dear Sir

Inquest touching upon the death of Thor Dalhaug

Thank you for providing me with the areas of concern requiring further investigation
under Schedule 5 of the Coroners and Justice Act 2009 and regulations 28 and 29
of the Coroners (Investigations) Regulations 2013. | write to provide the formal
response on behalf of the Trust.

However, knowing that this letter will also be read the family, | would like to
firstly reiterate my condolences to in, the very sad loss of their
child. We would also like to offer the family a chance to meet with the senior

representatives from the hospital to revisit and explain the changes that have been
put in place since Thor's passing.

In relation to the areas of concern raised, the Trust would like to comment as
follows:-

1. The failure to supervise the operating surgeon on her first day at work
for this complex twin delivery. It was stated in evidence that the policy
of inducting new staff had changed but this had not been enshrined in
any formal document. Such a copy should be produced and a copy
submitted to myself

The Trust's reopened investigation report identified this as a crucial factor. Whilst
review of individual factors is important, the Trust thought it appropriate to examine
the wider circumstances as to why the Registrar had been left in such a difficult
position without appropriate supervision on her first day at the Trust.

Whilst it is important to note that relevant competency checks are undertaken prior
to any doctor starting in the department, it is accepted that a new Registrar should

Chairman: Ron Buchanan
Chief Executive: Jane Lewington

not have been placed in a position where they had to carry out an emergency twin
caesarean section without appropriate support and supervision. As you heard in
evidence it had been the full intention of the consultant to supervise the birth, but
unfortunately she was called away to another emergency.

As indicated in the evidence heard at inquest, the Trust has now taken various
steps to significantly reduce the chance of such a situation occurring again. In
particular, all junior doctors will now:-

e Have a welcome session conducted by the Royal College of Obstetricians
and Gynaecologists Tutor or appropriate, nominated representative.

e Have a comprehensive tour of the department. This will include all clinical
areas in which they will be working, including wards, clinics, theatres and
secretarial offices. They will also be shown how to use the department
equipment, such as defibrillators, computers, and any other relevant
equipment required for their role.

e Undergo OSATS assessments in Caesarean section and Instrumental
Delivery prior to being able to perform these independently.

e Be shown how to access the guidelines and protocols of the department.

e Be given contact details of who to contact for any further queries.

e Follow up by an informal interview a few weeks into their post to address
any outstanding issues or concerns

e Lastly, and importantly, they will undergo a week of supernumerary activity
in different clinical areas to orientate themselves to the department and to
ensure that they will not be left unsupervised before ensuring that they are
both confident, and able, to perform the relevant actions required.

As such, a newly employed Registrar should not now be left unsupervised on their
first day of employment. To confirm, these actions are already in place with a
newly appointed Registrar having gone through this process in October 2014. We
also enclose in appendix 1 the new Trust Junior Doctor Induction document for
Obstetrics and Gynaecology, which has received executive Medical Director
approval.

2. The lack of any steps having been taken to discipline the clinicians
involved or limit their practice given their decision to adopt a wholly
inappropriate, unacceptable and unorthodox technique in delivering
Thor, resulting in his death.

Matters relating to disciplinary proceedings are confidential between the employee
and employer. The Trust would, however, like to offer you assurance that
appropriate management action has been taken including liaison with the relevant
regulatory authorities. The Trust would also like to make it clear that whilst it
acknowledges that the forceps delivery should not have been attempted, it did not
feel it appropriate to single out or blame any individual for the tragic events that
occurred that day during delivery. The Trust wished to analyse the wider context

Chairman: Ron Buchanan
Chief Executive: Jane Lewington

and the working systems and processes we had put in place. It is by undertaking
this wider analysis that more extensive changes can be made. It is hoped that this
will ensure wider learning and reflection by the department as a whole which in turn
will achieve more resilient improvements in patient safety.

For six months prior to March 2014, the Registrar was absent from work and
clinical duties. As was stated in evidence, since her return, there have been regular
meetings with the Registrar involved in Thor's delivery. The purpose of these
meetings was to review competence and abilities, to provide support, to ensure
adequate supervision, and for the Trust to assure itself of an appropriate and safe
return to practice. She initially undertook limited non-acute consultant supervised
clinical activity in the out-patient setting.

From May 2014, following satisfactory review and discussion with the wider
consultant body, it was felt that the Registrar could increase her elective
supervised clinical sessions in gynaecology only.

In November 2014, following satisfactory monthly reviews and discussions, it was
agreed that an increase in clinical activity to 7 sessions a week, an extension to
ward cover, and also assisting in day case surgery was appropriate. This was on
the understanding that she should not undertake any acute interventions without
the agreement and direct supervision of a Consultant.

It is not until more recently (March 2015) that the Registrar has returned to labour
suite and this has been in a supernumerary capacity, with consultant supervision.
The Registrar also keeps a log of her activity on the labour suite and has been
involved in a detailed reflective practice process as part of the incident. She is fully
aware as are the wider consultant body and midwifery staff that currently she must
not undertake any independent obstetric activity.

3. The failure to ensure a full contemporaneous record was kept by
doctors involved in a term neonatal. death. Such failure has seriously
hampered my investigation into the circumstances surrounding Thor’s
death and has resulted in serious difficulties to Thor’s family who
clearly struggled and suffered as a result of not being able to
understand why their son died shortly after his birth

It is accepted that contemporaneous recording of all events is important in
healthcare practice. By way of reassurance, the doctors who join the Department
are informed about the importance of ensuring a full contemporaneous record of
any clinical interaction at their Trust and departmental induction. The Head of
Service and the Consultant Labour Ward Lead undertake case study learning
sessions. Lessons about, but not limited to, documentation problems from this
case are included in the lessons learnt section.

In addition to the above, the Clinical Director has also written to the doctors
involved in this incident to remind them of their duties. To add to this, however, a
reminder has also been sent to doctors within the Directorate reminding them their
responsibilities with regards to clinical documentation. This letter has also been
circulated, by the Medical director, to all medical staff within the Trust.

Chairman: Ron Buchanan
Chief Executive: Jane Lewington

Whilst dissemination of learning is important, the Trust will also undertake spot
audits of operative notes, once a year for the next 3 years. This will be done after
annual change of middle grade doctors and facilitated by audit leads on both sites.
Should there be any failures from the audit; appropriate action will be taken until
the Trust is satisfied that there is a robust system of recording.

4. The failure to identify in the immediate aftermath of Thor’s death that
the operating surgeons had neglected to make full note of
circumstances in which he died and to obligate them to provide the
same; in particular the SHO was advised to amend the Caesarean pro
forma, to include the fact that forceps were used in the interest of
candour. He was then dissuaded from doing so by senior
management as a result of their concerns as to how this would be
perceived if the matter was investigated. This raises very serious
concerns as to the degree of candour in disclosing the circumstances
of his death. What steps have been taken to obviate a repetition of this
behaviour in the future?

The Trust accepted during evidence that the failure to make a contemporaneous
operating note fell below the standard to be expected of its staff. | would like to
reiterate the apology given in respect of this failure. This should have been
highlighted earlier, and rectified, during the Trust's investigation.

In relation to the steps taken, the importance of ensuring that the operating
surgeon writes their own notes and does not delegate it to another surgeon is
highlighted in the new induction programme delivered by the Head of Service and
Consultant Labour Ward Lead. | refer to response 1 above and appendix 1.
Finally, compliance will be audited in the first 3 months of the doctor’s employment
in the Trust by the Audit Lead.

In relation to the point raised regarding candour, the Trust would like to assure you
that this is a matter that is taken very seriously at the Trust. We were dismayed to
learn of the potential that a member of staff had been dissuaded from amending
the caesarean section pro forma. A thorough investigation has been undertaken,
but unfortunately the Trust has been unable to identify the individual who
apparently advised the SHO to adopt this practice. It should be highlighted that the
SHO completed a detailed statement fully disclosing that the use of forceps had
been attempted. Given that the SHO’s and Registrar’s statement both disclosed
the use of forceps, it is believed that the concern may have arisen that it was not
appropriate to amend original records some months after the death. The Trust fully
accepts, however, that any inference that a later timed addendum should not be
added to provide greater clarity to the records was not appropriate. By way of
reassurance, whilst reminding staff of the need to complete full contemporaneous
notes we will also be auditing the accuracy of information within medical records,
the Clinical Director and Head of Midwifery have written to all medical and
midwifery staff to remind them of their duties regarding candour.

Chairman: Ron Buchanan
Chief Executive: Jane Lewington

The duty of candour has been incorporated into our complaints policy. It is also
incorporated into our DATIX incident management system for moderate and severe
harms. The compliance with the documentation of duty of candour is reported
upwardly to the Quality Governance Committee — one of four sub-committees that
report to the Trust Board.

5. The fact that the consultant ultimately responsible for Thor was also
charged with undertaking the SUI report into his death. Further, that
the consultant signed off the original SUI report without having read
any of the statements referred to in that report

Please disclose the policy or means by which it has been made clear
that this should not happen in future

This was not appropriate and should not have happened. Since 2014 the Trust
has significantly reviewed and changed its processes relating to investigations
(please see Appendix 2).

No clinician involved with a clinical incident is allowed to lead or be involved with
the same investigation; this will be incorporated into Trust policy. The responsible
persons to ensure this takes place are the Medical director and our Head of
Governance. | believe our Head of Midwifery provided assurance at the Inquest
that all clinical incidents are now appropriately managed and _ investigated.
Furthermore, a weekly meeting takes place between the Medical director, the Chief
Nurse, Head of Governance and Lead for Risk Management to review and oversee
all serious incident investigation. This provides the level of rigour and scrutiny to
ensure the investigation is undertaken to a high standard. Furthermore, all Sl’s are
sent to the Clinical Commissioning Group and once these have been signed off
they are reported to our Trust Board, (please see appendix 2).

6. The fact that the original SUI and the revised version completed after
receipt of post mortem failed to disclose that there was no support for
the use of forceps to disimpact the foetal head.

At the time the original SUI was completed the post mortem was not available to
the Trust. It did not know, therefore, what the cause of death was. There was, as a
result, a concentration on events leading up to the delivery, including an analysis of
the antenatal care and the timing of the decision to proceed to delivery.

On receipt of the post mortem and the Registrar’s statement an addendum was
made to reference the fact that forceps were used. This was a second missed
opportunity to reopen and examine in more detail the use of forceps. It was not felt
at this time that the forceps had any causative impact on the death, which was
corroborated by your expert during the inquest. However, it is accepted that the
original SUI report was significantly flawed. Despite the belief that the forceps did
not play a role in the death, this should have been fully documented, analysed and

Chairman: Ron Buchanan
Chief Executive: Jane Lewington

reasons given for the conclusions drawn. The fact that this did not take place is
totally unacceptable and the Trust wishes to apologise unreservedly to the family
that this did not occur.

As stated above, the Trust’s governance and investigation procedures (please see
appendix 2) have changed substantially since the time of the initial investigation.
The Trust would like to offer its assurances that when a serious incident occurs,
there is a robust process behind the investigation with a full timeline and thorough
analysis of all actions undertaken.

7. The fact that no steps have been taken to discipline those involved in
the production of this wholly inadequate SUI.

The Trust has recognised that there were serious failures in the original
investigation, but these were compounded by a weak investigation process in place
in the Department at the time of Thor’s death, rather than an individual failure. It
has, therefore, undertaken a wholesale review of the culture, systems and
processes. Whilst it is accepted that there is still, and will always be improvements
to process, it is hoped that the information above provides assurance that there is
now an effective process in place to satisfy your requirements under the relevant
legislation.

As discussed at response 2 above the Trust is advised that it would not be
appropriate to discuss any disciplinary proceedings.

8. The fact that none of the statements served by the Trust disclosed that
there was no support for the use of forceps to disimpact the foetal
head.

The staff involved were asked to provide factual statements relating to their
involvement in Thor's management. The relevant statements relating to the
delivery included the fact that forceps were used. The analysis of whether or not
the use of forceps was indicated was a matter for the SUI report, not the factual
statements. This did not happen, which was wholly inappropriate. The Trust
accepts that the initial investigation report should have analysed the use of forceps.
The Trust apologises unreservedly for this, but hopes that the fresh SUI report,
along with the information detailed above, provides reassurance that the systems
are now in place to ensure full and thorough analysis of adverse clinical incidents.

9. The fact that there was a failure to recognise the inadequacy of the
operating surgeon’s original statement and SUI and that these
inadequacies were not addressed until | directed the Trust to obtain a
full statement and undertake a comprehensive SUI

As indicated above, the Trust apologises for the inadequate investigation that was
initially undertaken and would like to reassure you that process changes were
already underway at the time it was agreed that a fresh SUI was required. It is
hoped that the information that has been detailed above, together with the
supporting documentation, reassures you and the family that important and
relevant changes have been put into place for the future.

Chairman: Ron Buchanan
Chief Executive: Jane Lewington

Summary

| would like to conclude by repeating my apology for the substandard care that lead
to Thor’s death and for the subsequent poor governance that hampered your
investigation and clearly caused significant additional distress for the family. This
is a matter of great regret. Whilst | know that the actions taken cannot bring Thor
back | hope you and the family will be reassured that the Trust has put important
changes into place. | would like to apologise for the difficulty the family have faced
during this process, but the Trust does: and will continue to strive to provide the
best care it can for the community it serves. | was very sad to hear of the
circumstances of Thor’s death and | am sorry that we let Thor and his parents
down.

Yours sincerely

Jayne Lewington
Chief Executive
United Lincolnshire Hospitals NHS Trust

Chairman: Ron Buchanan
Chief Executive: Jane Lewington