Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0035, written 5 Feb 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 5 Feb 2016 |
|---|---|
| Reference | 2016-0035 |
| Deceased | Isla Lord |
| Coroner | Thomas Osborne |
| Coroner area | Bedfordshire and Luton |
| 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 R. Osborne
Senior Coroner for Bedfordshire and Luton
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Mr Philip Morley
Chief Executive
The Princess Alexandra Hospital NHS Trust
Hamstel Road
Harlow
Essex CM20 1QX
1
CORONER
I am Thomas R Osborne, Senior Coroner for Bedfordshire and Luton
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 19 November 2012 I commenced an Investigation into the death of Isla Peyton
LORD, aged 4 days . The Investigation concluded at the end of the inquest on 28
January 2016. The Conclusion of the Inquest was a ‘Narrative Conclusion’ that “…
Isla Peyton LORD was born on 4 November 2012 at the Princess Alexandra Hospital in
Harlow. Following delivery she suffered an inexplicable immediate post-natal collapse;
initial attempts at resuscitation were unsuccessful and she suffered a hypoxic ischaemic
brain injury. She was transferred to the Luton and Dunstable Hospital where she died on
8 November 2012.
4
CIRCUMSTANCES OF THE DEATH
Isla was born at Harlow Hospital on the 4th November 2012. During pregnancy, an
antenatal scan detected the right leg bent above the knee. There were also concerns over
an enlarged heart chamber. She was born by Emergency C Section; she cried upon
delivery, however, then collapsed. There was a prolonged period of resuscitation and she
was found to have a hypoxic brain injury. She was subsequently transferred to the Luton
Senior Coroner, The Court House, Woburn Street, AMPTHILL, Bedfordshire, MK45 2HX
Tel 0300-300-6559 | Fax 0300-300-8267
and Dunstable Hospital at 06.00 hours on the 5th November 2012, where she was
ventilated. Discussions then took place with Isla's parents when a decision was made to
withdraw treatment. She sadly died on the 8th November 2012.
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 –
1. During the course of the evidence it became apparent that once the possibility of
heart anomalies was identified at University College Hospital in London
(UCLH), there was no liaison between Princess Alexandra Hospital in Harlow
and UCLH as to the plan for the delivery of the baby. It was simply agreed that
UCLH were content for her to be delivered at the local hospital with a referral
being made to Great Ormond Street Hospital after delivery. In order to prevent
deaths in the future there needs to be a review of the system that exists between
the tertiary hospitals and Princess Alexandra Hospital as to how to formulate an
Agreed Delivery Plan for both mother and baby.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you as Chief
Executive of the Princess Alexandra Hospital 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 2nd April 2016. 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 :
Parents;
Chief Executive, University College London Hospitals (UCLH) NHS Foundation Trust,
235 Euston Rd, Fitzrovia, London NW1 2BU;
Senior Coroner, The Court House, Woburn Street, AMPTHILL, Bedfordshire, MK45 2HX
Tel 0300-300-6559 | Fax 0300-300-8267
Hertfordshire Safeguarding Children Board Team, Room 147, Postal Point
CHO143, County Hall, Hertford. SG13 8DF admin.hscb@hertfordshire.gov.uk
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 5th February 2016
………………………………….
TOM OSBORNE
Senior Coroner
Bedfordshire and Luton
Senior Coroner, The Court House, Woburn Street, AMPTHILL, Bedfordshire, MK45 2HX
Tel 0300-300-6559 | Fax 0300-300-8267
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.
The Princess Alexandra Hospital NES Trust Family and Women’s Services Health Group DE/MTW Princess Alexandra Hospilal Hamstel Road 8" March 2016 Harlow Essex CM20 1QX Confidential Mr Tom Osborne Senior Coroner for Bedfordshire & Luto' The Court House Woburn Street AMPTHILL Bedfordshire MK45 2HX 7 eo lalla Dear Mr Osborne RE: REGULATION 28 REPORT TO PREVENT FUTURE DEATHS | write further to your report following the investigation into the death of Isia Peyton Lord which requested a review of the system that exists between the tertiary centres and the Princess Alexandra Hospital on how to formulate an Agreed Delivery Plan for both mother and baby. | would like to assure you of the following: 1. The Standard Operating Policy for obstetric ultrasound scanning has been amended to include that consultants in charge of patients referred for second opinion in tertiary centres should request a detailed pian for delivery of the mother and care of the baby. The policy also requests the consultants to document the plan clearly in the patient’s hand held notes and hospital notes. 2. The new policy has been added to the Trust guidelines folder accessible by ail clinicians. 3. Obstetric doctors have been notified of the policy. 4. Referrals to tertiary centres will be notified to and monitored by the weekly Multidisciplinary Paediatric Plans of Care Meeting. | am confident that the above actions will ensure the prevention of avoidable neonatal deaths. Kind regards, Yours sincerely _ cr WN ry on \ . boven Bo ceeccteee Vd eee DEYA ELSANDABESEE PHIL MORLEY ANDY MORRIS Associate Medical Director / Chief Executive Chief Medical Officer Consultant Obstetrician SU & Gynaecologist Chair: Douglas Smallwood Chief Executive: Phil Morley www.pah.nhs.uk
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