Vasilis Ktorakis

Regulation 28:  Prevention of Future Deaths report 

Vasilis KTORAKIS (died 23.05.15) 

THIS REPORT IS BEING SENT TO: 

1. 

Executive Medical Director 
The Whittington Hospital NHS Trust 
Magdala Avenue 
London  N19 5NF  

1 

CORONER 

I am:   Coroner ME Hassell 
           Senior Coroner  
           Inner North London 
           St Pancras Coroner’s Court 
           Camley Street 
           London  N1C 4PP 

2 

CORONER’S LEGAL POWERS 

I make this report under the Coroners and Justice Act 2009,  
paragraph 7, Schedule 5, and  
The Coroners (Investigations) Regulations 2013, 
regulations 28 and 29. 

3 

INVESTIGATION and INQUEST 

On 28 May 2015, I commenced an investigation into the death of Vasilis 
Ktorakis,  who  died  shortly  after birth. The  investigation  concluded at  the 
end  of  the  inquest  on  5  October  2015.    (I  apologise  for  the  delay  in 
sending  this  report.)    I  made  an  open  determination  and  recorded  a 
medical cause of death of: 

1a  acute perinatal asphyxia 
1b  underlying cause unknown. 

4 

CIRCUMSTANCES OF THE DEATH 

Following a long labour at the Whittington Hospital, 
gave 
birth on Saturday, 23 May 2015.  To the great surprise of the healthcare 
team, Baby Vasilis was born in an extremely poor condition and died very 
shortly thereafter. 

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 5 

CORONER’S CONCERNS 

During  the  course  of  the  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.  

Errors in Care 

1. 

  was  started  on  Syntocinon  at  7.15pm  on  Friday,  22 
May 2015.  Given the circumstances of her presentation (including 
meconium  stained  liquor  and  infrequent  contractions  at  a  late 
stage  of  labour),  her  consultant  told  me  in  court  that  when 

was  seen  by  a  registrar  at  2.40pm  that  afternoon,  the 
full  review  and  started 

registrar  should  have  conducted  a 
Syntocinon then, some four and a half hours before.   

Having  spoken  to  the  registrar  since,  the  consultant  is  unable  to 
explain why that full review and medication commencement did not 
take place.  It is therefore unclear whether this particular registrar, 
and  indeed  others  on  the  unit,  might  be  likely  to  make  the  same 
mistake again another time. 

2.  The notes recorded by that registrar fell significantly short of what 

can be expected in terms of recording a management plan. 

Learning Lessons  

3.  At ten past midnight on Saturday, 23 May, a different registrar took 
the  decision  to  allow  two  hours  passive  descent  before  pushing.  
This  was  an  error  of  judgement  that  the  registrar  had  not 
appreciated even by the time of the inquest, over four months after 
death,  indicating  that  she  had  not  received  appropriate  feedback.  
It  is  therefore  unclear whether  this particular  registrar,  and  others 
on the unit, might be likely to make this same mistake again. 

4.  The  first  registrar  was  not  asked  to  contribute  to  the  hospital’s 
untoward incident investigation, so there was a systemic failure to 
understand the value of her input, resulting in a loss of learning for 
the organisation and for the registrar. 

5.  Neither  the  first  nor  the  second  registrar  was  notified  of  the 
untoward  incident  investigation  findings,  even  by  the  time  of 
inquest,  and  so  the  opportunity  for  them  to  learn  and  to  improve 
was lost.  This seems to demonstrate a lack of a robust system for 
learning lessons. 

2 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 6 

ACTION SHOULD BE TAKEN 

In  my  opinion,  action  should  be  taken  to  prevent  future  deaths  and  I 
believe  that  you  and  your  organisation  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 by 21 December 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 following. 

  HHJ Peter Thornton QC, the Chief Coroner of England & Wales 
 
 
 
 

, obstetric consultant 

 obstetric registrar 

 obstetric registrar 

 Vasilis’s parents 

I  am  also  under  a  duty  to  send  the  Chief  Coroner  a  copy  of  your 
response.  

The Chief Coroner may publish either or both in a complete or redacted 
or summary form. He may send a copy of this report to any person who 
he  believes  may 
interest.  You  may  make 
representations to me, the Senior Coroner, at the time of your response, 
about  the  release  or  the  publication  of  your  response  by  the  Chief 
Coroner. 

it  useful  or  of 

find 

9 

DATE                                                   SIGNED BY SENIOR CORONER 

19.10.15 

3

Regulation 28: Prevention of Future Deaths  

Action plan following the report of: 

Coroner ME Hassell 
Senior Coroner 
Inner North London 
St Pancras Coroner’s Court 
Camley Street 
London N1C 4PP 

Into the death of: 

Vasilis Ktorakis 

Identified MATTERS OF CONCERN for Whittington Health:  

No.  Matters of concern  

Key Actions 

Completion Date 

Responsible 
Lead(s) 

Progress on actions 
and dates: 

1  Ms Ktorakis was 

1)  Educational supervisor to 

29th January 2016 

started on Syntocinon 
at 7.15pm on Friday, 
22 May 2015. Given 
the circumstances of 
her presentation 

meet with the registrar (KA) 
and discuss the learning 
from this case.   

Vibha 
Ruparelia, 
Consultant 
Obstetrician  

Vibha Ruparelia met 
with the registrar 
shortly after the inquest 
and went through the 
learning from this case.  

Evidence of 
implementation and 
date of 
implementation (to 
be completed once 
actions are 
completed) 

1 

 
 
 
 
 
 
 
  
 VR to ensure the 
reflective statement 
has been completed 
and added to the 
portfolio as outlined.  

29th January 2016 
(these actions will 
take place 
throughout 
January and will 
be completed by 
the end of 
January) 

Clinical Risk 
Midwife and 

Consultant 
Obstetrician  

This case was 
originally shared with 
the maternity unit in 
August 2015 via the 
maternity newsletter  

2)  Registrar to complete a 

reflective statement which 
will be added to their 
training and appraisal 
portfolio. 

3)  Provide a summary of the  
case and all the learning 
points and share with staff 
via the maternity newsletter, 
maternity clinical 
governance committee, the 
weekly maternity teaching 
sessions and the trust 
intranet (the trust intranet 
includes a section for 
sharing learning from 
complaints and incidents). 

(including meconium 
stained liquor and 
infrequent 
contractions at a late 
stage of labour), her 
consultant told me in 
court that when Ms 
Ktorakis was seen by 
a registrar at 2.40pm 
that afternoon, the 
registrar should have 
conducted a full 
review and started 
Syntocinon then, 
some four and a half 
hours before.  

Having spoken to the 
registrar since, the 
consultant is unable to 
explain why that full 
review and medication 
commencement did 
not take place. It is        
therefore unclear 
whether this particular 
registrar, and indeed 
others on the unit, 
might be likely to 
make the same 
mistake again another 
time.  

2 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 2 

The notes recorded by 
that registrar fell 
significantly short of 
what can be expected 
in terms of recording a 
management plan.  

4)  As per action points 1 and 2 

above. 

5)  A regular audit of maternity 
records is undertaken (40 
sets of notes a year) and 
includes a review of 69 
standards.  Consultants and 
trainee doctors to be 
actively involved in the 
completion of the audit, 
presentation of the results 
and action planning. Results 
of the most recent audit and 
learning regarding record 
keeping in this case will be 
presented at the next 
clinical audit day (this is a 
trust wide multidisciplinary 
learning event). 

21st January 2016 

, 
Matron and 

Consultant 
Obstetrician 
and 
Oliparambil 
Ashokkumar, 
Consultant 
Obstetrician  

3 

At ten past midnight 
on Saturday, 23 
May, a different 
registrar took the 
decision to allow 
two hours passive 
descent before 
pushing. This was 

6)  Educational supervisor to 

29th January 2016 

meet with the registrar (SA) 
and discuss the learning 
from this case.   

7)  Registrar to complete a 

reflective statement which 

Chandrima Biswas met 
with the registrar 
shortly after the inquest 
and went through the 
learning from this case.  
CB to ensure the 
reflective statement 

Consultant 
Obstetrician 
and Divisional 
Director 

, 

3 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 an error of 
judgement that the 
registrar had not 
appreciated even by 
the time of the 
inquest, over four 
months after death, 
indicating that she 
had not received 
appropriate 
feedback. It is 
therefore unclear 
whether this 
particular registrar, 
and others on the 
unit, might be likely 
to make this same 
mistake again.  

The first registrar 
was not asked to 
contribute to the 
hospital’s untoward 
incident 
investigation, so 
there was a 
systemic failure to 
understand the 
value of her input, 
resulting in a loss of 
learning for the 
organisation and for 

4 

will be added to their 
training and appraisal 
portfolio. 

8)  As per action 3 above. 

9)  A meeting will take place 
with at the start of every 
maternity serious incident 
investigation that includes 
all the staff involved in the 
incident and the 
investigating team.  It will be 
agreed in this meeting who 
needs to provide a 
statement and contribute to 
the process. 

has been completed 
and added to the 
portfolio as outlined.  

Consultant 
Gynaecologist 
and Director 
of Research 
and 
Innovation  

COMPLETED 

, 

Maternity 
Clinical 
Governance 
Manager 

This was put in place 
immediately following 
the outcome of the 
inquest. 

4 

 
 
  
 
 
 
 
 
 
 
 
 the registrar.  

5 

Neither the first nor 
the second registrar 
was notified of the 
untoward incident 
investigation 
findings, even by 
the time of inquest, 
and so the 
opportunity for them 
to learn and to 
improve was lost. 
This seems to 
demonstrate a lack 
of a robust system 
for learning lessons. 

31st December 
2015 

10)  A multidisciplinary meeting 
(MDT) will take place at the 
conclusion of every serious 
incident investigation that 
includes all the staff 
involved in the incident and 
the investigating team.  

A wider MDT will take place 
involving other staff on the 
unit as relevant. 

Arrangments for 
this to be in place 
by 29th January 
2016 

31st December 
2015 

11)  The serious incident action 
plan template will include a 
preset recommendation for 
completion that stipulates 
feedback must be given to 
each individual involved 
who requires feedback.  The 
action will need to include 
who will provide the 
feedback and when this will 

, 

Maternity 
Clinical 
Governance 
Manager 

, 

Consultant 
Obstetrician 
and Divisional 
Director 

Head of 
Integrated 
Risk 
Management 

5 

 
 
  
 
  
  
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
  
 be done.   

12)  Medical Director to write to 
all Divisional Directors 
regarding the importance of 
robust record keeping and 
for this to be cascaded to all 
staff within their clinical 
services. 

29th January 2016 

Medical 
Director 

6