Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0393, written 29 Sep 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 29 Sep 2015 |
|---|---|
| Reference | 2015-0393 |
| Deceased | Ethan Johnson |
| Coroner | Thomas Osborne |
| Coroner area | Milton Keynes |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Thomas Ralph Osborne
Senior Coroner for Milton Keynes
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO: The Chief Executive of Milton Keynes Hospital
1
CORONER
I am Thomas Ralph Osborne, Senior Coroner for Milton Keynes
2
CORONER’S LEGAL POWERS
I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and
regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
3
INVESTIGATION and INQUEST
On 06/01/2015 I commenced an investigation into the death of Ethan Robert Johnson. The
investigation concluded at the end of the inquest on 15th September 2015. The conclusion of the
inquest was Narrative as follows: The deceased was born on 4th January 2015 at 13.46. Prior to
his delivery he suffered perinatal asphyxia and meconium aspiration. The problem with his
wellbeing were first identified by an abnormal CTG at 12.15 and the delay in his subsequent
delivery by caesarean section resulted in a lost opportunity to deliver him earlier and render
further medical treatment. His cause of death was given after a post-mortem examination as 1a)
Meconium Aspiration 1b) Perinatal Asphyxia
4
CIRCUMSTANCES OF THE DEATH
Ethan Johnson was a new born baby. His Mother was admitted to the Maternity Unit for
induction of labour at 40+11 weeks.
Mum informed midwife on admission that there had not been foetal movements felt since 9pm
the night before admission but said that this was her normal pattern of movements. CTG on
admission showed a non-reactive trace. Mum spontaneously ruptured membranes and thick
meconium was noted. Mum was transferred to Delivery Suite and repeat CTG was deemed
pathological. A Category One (Urgent) Caesarean Section was performed under general
anaesthetic. There was some difficulty during the delivery and Ethan was born at 1.46pm with no
respiratory effort, no heart rate and was floppy and pale. Resuscitation was commenced
immediately, his airway was inspected under direct vision by SHO and copious amount of thick
meconium aspirated from beneath vocal cords. Resuscitation was carried out and a heart rate
was first detected at 35 minutes of age. Ethan was transferred to the Neonatal Unit at 2.44pm.
He was still undergoing various treatments and was discussed with a tertiary Neonatal
Consultant at the John Radcliffe Hospital. He felt that the situation and outlook was extremely
poor and advised discussing withdrawal of intensive care with the parents. A discussion was
held with both parents at around 4pm and the decision was made to withdraw treatment. Ethan
was extubated at 11.30pm and his death was confirmed at 3.26am on 05/01/2015.
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. –
HM Coroners Office, Civic Offices, 1 Saxon Gate East, Central Milton Keynes, MK9 3EJ
Tel 01908 254326 | Fax 01908 253636
(1)That the most junior member of staff (midwife) was left to look after
though the CTG trace was deemed abnormal. The midwife felt unsupported.
(2) Two further members of staff reviewed the CTG trace and yet it appears that no one was in a
position of leadership to require a doctor to attend and review the trace and
(3)When the consultant on call was requested to attend he indicated that he would do so later.
No one on the unit had the leadership role to insist upon his attendance.
(4) No one on duty in the unit was able to assume the leadership role and be in a position to offer
advice, support and to direct the course of events.
(5) There appeared to be a lack of understanding by members of staff as to labour ward
management because of the lack of effective leadership.
(6) There still appears to be a hierarchical approach to escalation of care within the unit.
even
HM Coroners Office, Civic Offices, 1 Saxon Gate East, Central Milton Keynes, MK9 3EJ
Tel 01908 254326 | Fax 01908 253636
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you 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
24th November 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:
• The family of Ethan Johnson and their solicitors
• The Local Safeguarding Children Board
• The Care Quality Commission
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 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 Chief Coroner.
9
Dated 29th September 2015
Signature_________________________
Mr Tom Osborne
Senior Coroner for Milton Keynes
HM Coroners Office, Civic Offices, 1 Saxon Gate East, Central Milton Keynes, MK9 3EJ
Tel 01908 254326 | Fax 01908 253636
1 response 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.
Milton Keynes University Hospital NHS|
NHS Foundation Trust
Standing Way
Our ref: JH/SW/151123 Eaglestone
Milton Keynes
MK6 SLD
23" November 2015 01908 660033
www.mkhospital.nhs.uk
For people who have hearing loss
Minicom 01908 243924
Private and Confidential
Mr Tom Osborne
HM Coroner
Civic Offices
1 Saxon Gate East
Milton Keynes
MK9 3EJ
Dear Mr Osborne
Re - REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
Thank you for your letter of 29" September 2015, raising concerns following the Inquest into
the death of Ethan Johnson. The Trust is always willing and eager to develop and make
changes to improve the care it provides to the local population and has considered the
matters you raise and responds as follows:
1. That the most junior member of staff (midwife) was left to look ate TTT...
though the CTG trace was deemed abnormal. The midwife felt unsupported,
In this particular case the concerns were identified and appropriately escalated within a few
minutes. All our junior midwives are fully qualified and are conversant with the escalation
process and how to summon help in an emergency. All staff have been reminded of this
process.
In response to your concern, however, the new Head of Midwifery has strengthened the
preceptorship period for newly qualified midwives. This means that they are supernumerary
for several weeks and will be supported by experienced senior practice development
midwives, whilst being familiarised in departmental processes.
Furthermore, 2 hourly ‘intentional rounding’ of all patients undergoing 1:1 care (antenatal,
labour, and postnatal) by a Band 7 Co-ordinator is now in place to ensure that appropriate
care is being given through support of the patient’s individual midwife.
In addition, a ‘safety huddle’ has been implemented. This is a meeting at the delivery suite
whiteboard, consisting of the Labour Ward coordinator and medical teams, including the
Consultant. This ensures that all staff are aware of each patient's clinical status and their
As a teaching hospital, we conduct education and research to improve healthcare for 5 faye .
We ¢ ARE our patients. During your visit students may be involved in your care, or you may be eet Bamet
asked to participate in a clinical trial. Please speak to your doctor or nurse if you have .
any concems.
management plan. The department is also in the process of changing the existing patient
whiteboard, to include time of doctor review in cases where the CTG trace is deemed
suspicious.
2. Two further members of staff reviewed the CTG trace and yet it appears that no one was
in a position of leadership to require a doctor to attend and review the trace and
On the ward the CTG did not require immediate intervention, so when the doctor had not
attended within a reasonable timescale it was escalated appropriately. We have written to
every member of staff clarifying their responsibilities if they are asked to review a patient, as
well as what to do if senior help has been unable to attend. This includes timescales for
upward escalation.
‘Fresh eyes/ears’ stickers have been introduced to ensure hourly senior review of both
intermittent and continuous fetal monitoring.
Central Electronic Fetal Monitoring has now been installed and an internationally renowned
expert on fetal monitoring has delivered training in the Trust.
3. When the consultant on call was requested to attend he indicated that he would do so
later. No one on the unit had the leadership role fo insist upon his attendance.
The Consultant attended delivery suite within 14 minutes of _ is an
appropriate time for the case for which he was called (i.e. not :
Anew, specifically dedicated Matron for Labour Ward has ensured that a revised handover
communication tool (SBAR) is embedded in practice, so that a succinct common language is
in place to enable the medical staff to make an appropriate assessment of when to attend.
There is now a Manager of the Day on the Maternity Unit.
4. No one on duty in the unit was able to assume the leadership role and be in a position to
offer advice, support and to direct the course of events.
SB riven on delivery suite at 13.10 hours, monitoring was commenced at 13.13
hours, and conce pparent with the acute fetal bradycardia (low heart rate) at
13.25 hours a was already on delivery suite managing a
sep: | emergency. At this point he directed tn: Registrar) to deal
i —— in the first instance and the appropriate management plan was carried out
by taking her immediately to theatre to expedite delivery of the baby.
Therefore appropriately directed to deal with one problem whilst he
dealt with the other. {NM is an experienced obstetrician, and the difficulties
encountered during the procedure (caesarean section) could not have been predicted.
5. There appeared to be a lack of understanding by members of staff as to Labour Ward
management because of the lack of effective leadership.
We note)fEEEEEEeoncerns about the apparent chaotic situation; however, the
situation had changed from needing routine intervention, to the recognition that an extreme
emergency had developed, requiring the baby to be delivered within 30 minutes.
Our staff practice emergency scenarios such as this on a regular basis where each member
of the multidisciplinary team has a clearly designated role, but in this case the unexpected
difficulties encountered at delivery of Ethan Johnson could not have been foreseen.
We fully acknowledge that we should have de-briefed a .. that this situation
could have been clarified.
6. There still appears to be a hierarchical approach to escalation of care within the unit.
There are existing clear instructions for all midwifery staff, from new Band 5 Midwife to
Matron level and also for all levels of medical staff in respect of escalation to a Consultant.
Please see copy of written policy which has been recirculated to all staff.
Joint leadership training for Senior Midwives and Consultants will be undertaken in January
2016 which will further strengthen multidisciplinary team-working.
We are also currently reviewing of role of our Consultant Midwife in terms of supporting
clinical leadership on Labour Ward.
We trust that this addresses your concerns. Should you wish the Trust to provide any further
information in respect of this issue, please contact me.
Yours sincerely
je
Joe Harrison
Chief Executive
C.c.
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