Casey Garrett

2 a. Health Education East of England

2-4 Victoria House
Capital Park Fulbourn
Cambridge

CB21 5XB

STRICTLY PRIVATE AND CONFIDENTIAL

Mr Tom Osborne,

HM Senior Coroner for Bedfordshire and Luton
Coroner's Office

The Court House

Woburn Street

Ampthill, Bedfordshire

MK45 2HX
Date: 22 September 2015

Dear Mr Osborne

Re: Baby Casey Paul Garrett (Deceased)
Response to Regulation 28: Report to Prevent Future Deaths to Health Education

England

Please find below the response of Health Education England following the inquest into the
death of Baby Casey Paul Garrett and the Regulation 28 Report which you issued on 34
August 2015.

Your concerns were set out in the Regulation 28 Report as follows:

“My concern was regarding the clinical learning environment, in that a Student Midwife was
working with a Midwife and witnessed / carried out entirely inappropriate midwifery care
which led to this infant’s death, including insufficient foetal monitoring, misinterpretation of
a CTG trace and the failure to escalate the level of care when there was a “deviation from

the norm”.

The MATTERS OF CONCERN are as follows:-

Health Education East of England

1. The incident raises questions about the suitability of Bedford Hospital NHS Trust
being used as a clinical learning environment for Student Midwives — this needs an
urgent review in the interests of safety of mothers and babies to avoid similar deaths

in the future.

Response of Health Education England

Health Education England (HEE) exists for one specific purpose; to support the delivery of
excellent healthcare and health improvements to the patient and English public by ensuring
that our workforce has the right numbers, skills, values and behaviours, at the right time

and in the right place.

Health Education England is organised into 13 Local Education and Training boards. The
University of Bedfordshire and the Bedford Hospital NHS Trust at which the student was on
placement fall within the geography of Health Education East of England (HEEoE) therefore
all actions and monitoring are overseen by HEEoE.

Following the incident, a full internal investigation was completed by Bedford Hospital NHS
Trust and the University of Bedfordshire into the suitability of the learning environment. It
was established that the events that had led to the tragic death of Baby Casey Paul Garrett
did not reflect any wider issues with the supervision and education of midwifery students at
Bedford Hospital. Analysis of current supervision and capacity indicates in excess of a 2:1
ratio of mentors to students, all of whom have undertaken a recent mentorship

programme.

The investigation also confirmed that the placement was audited in July 2015 and at that
time fully complied with NMC standards. In addition to the requirement that each student
has a named mentor, HEEoE also require all students to have regular visits by academic staff
throughout their placement and are allocated a personal tutor from the university for the
duration of their programme.

However, additional work is now underway to ensure that the maternity unit continues to
further enhance its clinical learning environment. For example the Deputy Director of
Nursing, is holding Open Access Events for student midwives and has arranged Listening

Health Education East of England

Events to capture ongoing opportunities for further development of the learning

environment

Triangulation
HEE is responsible for education and training across many healthcare professions and

disciplines. Of particular relevance is training of doctors specialising in Obstetrics and
Gynaecology which also takes place at Bedford Hospital. Through our quality management
processes we have consistently found Bedford Hospital to provide excellent training and
supervision of trainee doctors in the maternity department and of Obstetrics and

Gynaecology registrars in particular.

in considering Clinical Learning Environments HEE also triangulates our evidence and
impressions with others assuring quality including the Care Quality Commission, Clinical
Commissioning Groups and through information shared at the Quality Surveillance Group.
This triangulation supports the use of this department at Bedford Hospital as a Clinical

Learning Environment.

HEEoE, since being notified of the incident has been working closely with Bedford Hospital
NHS Trust and the University of Bedfordshire to provide input to the development of an
appropriate action plan (see attached).

A summary of the actions to be taken forward is outlined below.
Summary of actions

Raising Concerns
An initial review of the learning environment has identified that whilst students are

allocated a trained mentor and a personal tutor and visited by a link lecturer during their
time on placement, further work should be undertaken to enhance each student’s
confidence and staff’s response to raising concerns. Action will therefore be undertaken by
Bedford Hospital NHS Trust to develop local leadership and to facilitate a positive reaction
to students raising concerns. At the same time the University of Bedfordshire will develop
their teaching and further emphasise the professional responsibility of students in this area.

Health Education East of England

Placement suitability
The placement was audited in July 2015. The University will quality check all active

placement audits to ensure consistency of approach and progress on action plans.

On-going placement evaluation and monitoring
Each placement is formally reviewed every 12 months, in accordance with the NMC

standards.

Every student completes a post placement evaluation. University of Bedfordshire and
HEEoE will monitor these carefully and implement any necessary remedial actions. This will
be achieved through increased link-lecturer involvement within the placement area, sharing
of student feedback and joint action with Bedford Hospital NHS Trust.

Student supervision

Whilst the feedback on the midwifery learning environment from students is very positive
overall, it is recognised there remain further opportunities for improvement in the
supervision of students. Bedfordshire Hospital NHS Trust is therefore implementing a
number of steps to support workforce development and to enhance the learning culture
within the midwifery team. The Director of Nursing will establish a student forum with free
access to the senior nursing team. The University of Bedfordshire will revisit its mentorship
programme and mentor education to further enhance the support given to midwifery
students. Please see attached action plan developed by the University of Bedfordshire and
Bedford Hospital NHS Trust in response to the investigation.

Bedford Hospital NHS Trust is working with the Bedfordshire Clinical Commissioning Group
and the University of Bedfordshire to review all serious incidents, as well as their gap
analysis from the recent Morecombe Bay Investigation (DH 2015).

Health Education East of England will continue to work with both the University of
Bedfordshire and Bedford Hospital NHS Trust to ensure the above actions and the attached
action plan are delivered. Through the Quality Improvement and Performance Framework,
we will continue to dedicate resources and support to ensure the learning from this incident
is shared and adopted across all of the commissioned programmes and learning

environments within our provider Trusts.

Health Education East of England

Please do not hesitate to contact me if you require any further information in relation to our
response.

Yours Sincerely,

Chairman