Archie Hexall

Lewisham and Greenwich

Queen Elizabeth, Woolwich

Dr P Barlow Stadium Road
Her Majesty's Assistant Coroner Woolwich

London
Inner South District, Greater London SE18 4QH

Southwark Coroner's Court

Tel: 020 8836 6000
1 Tennis Street
Southwark Chief Executive’s Office

SE1 1YD

17™ April 2015

Dear Dr Barlow

Re: Regulation 28 to Prevent Future Deaths report re Archie Hexall

| am writing in response to your Prevention of Future Deaths (PFD) Report dated 6" March
2015 received following the inquest into the death of baby Archie Hexall.

Your report informed me that at the inquest it was established that Archie, the eldest of twins
had been born on 24" March 2013 at Queen Elizabeth Hospital Woolwich by forceps delivery
in seemingly good condition. About 2 hours later he suffered a respiratory arrest. He was
found to have had extensive brain haemorrhage and hypoxic ischaemic encephalopathy,
although the underlying cause of these remains unknown. He was transferred to SCBU then
to St Thomas’ Hospital where he died on 29 March 2013 at the age of 5 days. Breakdowns
in communication between healthcare professionals and with Archie’s parents contributed to
the delay in recognising Archie’s deteriorating condition. The Trust undertook a Serious

Incident investigation following the incident.

You further expressed concern that future deaths could occur should the following issues not

be acted upon:

1 - Communication had been lost during handover between two midwives, contributed to by
the fact that notes of observations of Archie’s condition at the time had been written on a
loose piece of paper then later transcribed into the clinical notes once they had become
available. Not ail the observations were transcribed

across and it appears that important information about possible further signs of respiratory
distress had been lost. The loose piece of paper was not retained in the medical records and
you were concerned that it ought to have been.

2 — The midwife who had noted some concerns about Archie’s breathing had not expressed
these concerns to his father; had Archie’s father been aware of the concerns he would have
raised the alarm earlier when he later noticed that Archie’s breathing had become more
irregular. It is important that clinicians share relevant information with parents to enable them
to make important contributions to their child’s care; such an opportunity was lost in this

case,

! am now writing to set out what we have done within the Trust, and indeed were already in
the process of doing in relation to communication issues, to act upon these concerns, and
reduce the likelihood of avoidabie harm to future patients.

| have been assisted in this response by Head of Midwifery for our Maternity
Service which is now run across two hospital sites (Queen Elizabeth Hospital Woolwich and
University Hospital Lewisham) making up the current Lewisham and Greenwich NHS Trust.

1 — Documentation

This issue was raised by the PFD report in relation to loose paper being used to document
observations contemporaneously and later transcribed into the clinical notes. In this case the
observations taken from Archie were transcribed into the clinical notes by a different person
to the member of staff who had performed the observations. All members of staff have been
reminded that any loose documentation must be secured into the main clinical notes even if

written on a small piece of paper.

2 — Wider Communication issues

Communication is recognised by the Maternity service as a vital component to the care we
deliver. Communication both between teams of professionals and between professionals
and families for whom we are caring can be challenging at times, especially during
emergency and complex situations. It is however recognised as very important.

Just 5

This daily communication meeting is held daily (Monday to Friday) and is attended by all staff
working in the maternity unit that day. Issues such as recent clinical incidents, complaints
and user feedback are discussed.

After Action Reviews

An AAR is held following incidents, compiaints or when a complex case has gone very well,

to help learn lessons and share good practice. The maternity unit is working hard to embed
the AAR technique in everyday working life to encourage learning to be initiated by front line
staff.

Midwifery Mandatory Training

Communication issues are presented and discussed at the mandatory training days. In
addition all staff attend training on communication in various forms. Conflict resolution
training is also a Trust mandatory training element and there is strong focus on
communication skills and strategies.

SBAR

Work is currently underway to embed the use of this communication tool (Situation,
Background, Assessment, Recommendation) within the maternity service. This is a simple
tool used by many NHS organisations to ensure that communication between healthcare
professionals is clear and concise, and to support effective escalation of situations when

necessary.

This technique is already underway in the Children’s Division, the Maternity Service, and has
been incorporated into a wider Trust initiative under the umbrella of the national Sign Up To
Safety campaign and our pledge to reduce harm to the ‘deteriorating patient’. Progress will
be monitored at the Trust’s Quality and Safety Committee where quarterly updates will be
presented by the pledge leads. This committee is chaired by the Trust’s Deputy Medical
Director for Quality and Safety.

May | express on their behalf to Archie's parents the condolences of the staff involved, and
hope that they too will be reassured that the Trust is trying hard to improve communication
with parents within the Maternity Service, and thank them for their contribution to raising

awareness of these important issues.

eaReUNR tan RR TT

Within the maternity service there are several forms of training and updating for both
obstetric and midwifery staff to ensure that communication skill remains high on our agenda.
Within the medical workforce the consultants undergo a yearly appraisal. One domain
assessed is communication with colleagues and other health professionals. In addition it is
now mandatory that a 360 degree appraisal is completed every three years. The appraisal
focuses on working relationships as well as communication.

Communication skills are addressed as part of junior medical staff training with 360 degree

feedback being mandatory every two years.

Several communication workshops have been heid over the past few years both
multidisciplinary and involving women and their partners who have used our service.
Feedback from service users is considered a very important part of learning. Some other
initiatives which have been used to improve communication between staff and service users

include:

Goldfish Bowl

This initiative has been held three times within our Trust with excellent feedback from those
who attended. Members of the multidisciplinary team are invited to listen to the experience
of women who have used the service. These may be positive or negative experiences. After
this the audience discuss who women felt about the care they received and what

improvements could be made.

‘Whose Shoes?’

This was piloted by Lewisham and Greenwich NHS Trust as an initiative across London to
improve women's experience of maternity services. Again the audience is multidisciplinary
and each small group includes one or two service users. There is debate about how care is
delivered, the impact of the language we use, and how we involve families in their care.
Following the event pledges are made by those attending as to what they will-change. This
event was heid in November 2014, and second session is planned for spring / summer 2015.

Joint Teaching Session
Biannual joint teaching sessions are held for midwives and medical staff on cornmunication
skills. These sessions are facilitated by a consultant obstetrician and a supervisor of

midwives.

rea ena

| hope that this information about the initiatives that have been started since Archie's death -

provide you with assurance that the Trust is actively using different techniques to help
improve communication both within and between clinical teams and between clinicians and
patients and their carers, We have also raised awareness about the importance of retaining
all clinical documentation. The Trust is also actively participating in the national Sign Up to
Safety campaign with a Trust wide initiative to reduce avoidable harm from failure to identify

and act on the deteriorating patient.

Yours sincerely

Tim Higginson
Chief Executive