Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0130, written 31 Mar 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 31 Mar 2015 |
|---|---|
| Reference | 2015-0130 |
| Deceased | Thomas Beaty |
| Coroner | Lisa Hashmi |
| Coroner area | Manchester North |
| Category | Child Death (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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. Chief Executive, Pennine Acute Hospitals NHS Trust 2. Royal College of Obstetricians & Gynaecologists 3. Department of Health I CORONER I am Ms L J Hashmi, Area Coronerfor the Coroner area of Manchester North 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroner’s and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On the 2th4 March 2015, I commenced an investigation into the death ofinfant Thomas Beaty 4 CIRCUMSTANCES OF DEATH On the 1th1 April 2014, the deceased’s mother went into spontaneous labour (39 weeks gestation). There was delayed stage II and as a result, the medical team caring for mother and baby proceeded to manually rotate the foetus (he was in malpresentation), to carry out a trial of instrumental delivery (forceps) in theatre with an action plan set in the event thatthis intervention failed. The instrumental delivery was abandoned, baby’s head manually disimpacted and an emergency caesarean section carried out. At birth (00:31), the deceased’s APGARS were good and he appeared healthy. A cord blood gas wastaken, the result ofwhich was marginally abnormal. At 02:20, the deceased started to bleed and rapidly collapsed. He had suffered a catastrophic head injury (a rare but recognised complication of necessary medical intervention) resulting in hypovolaemic shock and hypoxic brain ischaemia. He developed bleeding complications (disseminating intravascular coagulation), deteriorated rapidly and died 26 hours after birth. 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 report to you. The MATTERS OF CONCERN are as follows: 1. Instrumental Delivery Guidance the Court heard how local/national protocols and — training programmes are routinely based on guidance issued by the Royal College of Obstetricians and NICE. The guidance in use at the time of Thoma& birth was found to be ambiguous, misleading and potentially open to misinterpretation. A key example was: ‘When to abandon the procedure: • No evidence of progressive descent with each pull • No evidence of imminent birth following 3 pulls of a correctly placed instrument by an experienced operator...’ The first point by implication must mean that where there is no descent with the first pull, then the procedure oughtto be abandoned, yet the second point suggests abandonmentafter a 3rd traction. 2. Terminology The RCOG Guidance did not provide operational definitions for words such - as ‘imminent’ (vis a vis birth) or ‘crowning’. This was particularly important in Thomas’ case, as it had a bearing on the decision making processes applied during the course of the forceps delivery. 3. Traction The term ‘gentle’ (traction) forming the ‘G’ of the algorithm within the Trust’s - protocol was misleading and not in line with the RCOG Guidance. The clinical evidence suggested that in most (if not all) cases mild to moderate traction is routinely applied by clinicians in order to ensure safe and successful instrumental delivery. Whilst it was accepted that this was often subjective, the term ‘gentle’ was clinically out with. 4. Development of Trust Guidance it is difficult for Trusts to change their guidance until — and unless there is a change/material improvement in the Guidance issued by the RCOG. 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 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 the 27’’ May 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 sent a copy of my report to the Chief Coroner and to the following Interested Persons namely: Thomas’ parents (via their legal representative) - (via her legal representative) - I am also under a 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 by the ChiefCoroner. Date: :2(Th Th .
2 responses 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.
A FronBen GummerMP ParliamentaryUnder SecretaryofState forCare Quality Department RichmondHouse of Hea th 79Wh’t h II London SW1A2NS POC5 931741 f Tel: Lisa Hashmi Area Coroner Greater Manchester North 22 JUL 2015 HM Coroner’s Court - The Phoenix Centre Heywood OL1O 1LR Ltc ph Thank you for your letter ofto the Secretary of State for Health about the death ofbaby Thomas. I am responding as the Minister with responsibility for maternity policy at the Department ofHealth. I was so very sorry to hear ofbaby Thomas’ death. The death ofa child is always a terrible tragedy and my heart goes out to Thomas’ parents. I would be grateful ifyou would pass my condolences to them. Your report detailed the terrible sequence ofevents which led to baby Thomas’ birth and injury on 1th2 April 2015. You had a number ofconcerns about the guidance issued by the Royal College of Obstetricians and Gynaecologists (RCOG), which the inquest found to be ambiguous, misleading and potentially open to misinterpretation, giving the example that the RCOG guidance did not provide operational definitions for words such as ‘imminent’ (vis a vis birth) or ‘crowning’. You also noted that it is difficult for Trusts to change their guidance until and unless there is a change/material improvement in the guidance issued by the RCOG. While local maternity and neonatal care providers must determine how best to deliver services in their area, in doing so we would expect them to give due regard to RCOG and other professional guidance. To this end, a copy ofyour report has been sent to the RCOG to make them aware ofthe concerns you have raised and I understand that they have responded to you directly. I thank you foing this matter to our attention. BEN GUMMER a I;
the Pennine Acute Hospitals ifcaling please ask for. | id North Manchester Genera! Hospital Direct Line: | Delaunays Road Crumpsait Seoretay ; Manchester M8 5RB one ‘eh May 2044 emt PF Strictly Private and Confidential Ms L J Hashmi Area Coroner Manchester North Dear Ms Hashmi Re: Inquest for Baby Thomas Beaty — 24" — 27" March 2015 | am responding to the concerns you raised in the Regulation 28 Report to Prevent Future Deaths issued on 31% March 2015, in relation to Baby Thomas Beaty. In tight of the findings from the inquest and the investigation the Trust has taken the following actions described below. instrumental Detivery Guidance Since the sad death of Thomas Beaty, the Trust reviewed and revised the Guideline for Assisted Vaginal Delivery in order to provide staff with greater clarity and guidance regarding the requirement for Consultant presence for trial in theatre if the operator is less than ST6. Additional guidance was also added with tegards to the flexion point, complications of instrumental deliveries, and disimpaction of the head. This guideline was ratified in December 2014, Immediately following the inquest a directive was issued to the obstetric medical team highlighting the requirement for a Consultant Obstetrician to be present in theatre for all trials of instrumental deliveries regardless of the level of experience of the Middle Grade operator. The guideline was amended to reflect this requirement and an audit undertaken on beth inpatient sites in April to provide assurance that this requirement was being met consistently. Upon receipt of the concerns you raised in the Regulation 28 Report to Prevent Future Deaths the guideline has been reviewed and revised further in order to address the areas that were considered ambiguous, misleading and potentially open to misinterpretation. 4. Instrumental Delivery Guidance Guideline amended to state to abandon the procedure * When there is no descent even after the 1st pull, 2. Terminology An explanation of the terms imminent and crowning has been added to the guideline. It is now stated in Section 6.2.6: * If delivery is imminent as evidenced by crowning (when the widest part of the baby's head (bi-parietal diameter) is at the perineum and does not slip back in between contractions) 3. Traction The guidance around traction was taken from the ASLO (Advanced Life Support in Obstetrics) course manual and has been amended and the term ‘gentle’ removed. The 'G’ of the algorithm now reads: G: Moderate traction, by pulling downwards, sweeping in a large are towards the operator, almost compieting a 180 degree curve (Pajot’s manoeuvre). 4. Development of Trust Guidance We have made interim changes to the Trust guideline whilst waiting for the RCOG to respond to the recommendations. However we will review again once the RCOG recommendations have been received. The amended guideline has been circulated to the obstetric medical team for their comments. The final document will be ratified in June 2015 and a copy will be sent to you following this. | am also including the Guideline for Assisted Vaginal Delivery for your information. | woutd wish to offer sincere condolences on behalf of myself and the maternity team to Thomas’ parents and family. Kind regards. Yours sincerely Acting Medical Director
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