Lincoln Brady

Chief Executive’s Office 
 The Murray Building 
The James Cook University Hospital 
Marton Road 
Middlesbrough, TS4 3BW 

Tel: 
Web-site: www.southtees.nhs.uk 

SM/CR-07 

3 May 2016 

PRIVATE AND CONFIDENTIAL 
The Coroners Service 
Middlesbrough Town Hall 
Albert Road 
MIDDLESBROUGH      TS1 2QJ 

For the attention of Miss C Bailey, Acting Senior Coroner for Teesside 

Dear Miss Bailey 

INQUEST INTO THE DEATH OF BABY LINCOLN JAMES BRADY 

This  is  a  response  to  the  Regulation  28  Report  sent  to  the  Chief  Executive  of  South  Tees  NHS 
Foundation Trust (the Trust) on 23 March 2016. 

The  background  to  this  report  is  that  the  inquest  into  the  death  of  Lincoln  Brady  was  concluded 
after  one  day  upon  hearing  compelling  independent  evidence  that  Lincoln  was  a  stillbirth.    In 
advance of the inquest, the Trust had been asked to provide a witness to address the issues as 
, Consultant Obstetrician and the 
identified in the Trust's internal investigation.  
Obstetric  lead  on  risk  management  within  the  Trust,  provided  written  evidence  for  this  purpose.  
  had  also  been  included  in  the  inquest  witness  list  to  address  the  Coroner  on  these 

issues orally. 

The  Trust  is  disappointed  that,  in  spite  of  this  evidence  being  readily  available  and  in  spite  of  a 
specific  request  for  evidence  to  be  heard;  the  Trust  was  denied  the  opportunity  of  having  this 
evidence  entered  onto  the  formal  record  of  the  inquest.    The  Trust  would  have  welcomed  the 
opportunity  to  provide  assurances  to  the  Coroner,  the  family,  and  the  wider  public  that  Lincoln's 
death was carefully investigated and significant changes were made as a result. 

Had this opportunity been given, in addition to the documentary evidence, you would have heard 
  around  the  significant  steps  taken  to  improve  practices  and 
oral  evidence  from 
procedures  in  maternity  care  as  a  result  of  this  incident.    This  response  sets  out  only  those 
measures taken to address the areas of concern highlighted in the Regulation 28 report, namely 
that:  

1  The findings of the abdominal and vaginal examinations did not correlate 
2  No further investigations, including an ultra sound scan were carried out 
3  This prevented appropriate planning including discussion around preferred method of delivery 

For the avoidance of doubt, the measures set out below were in place in advance of the inquest 
commencing and are not steps that have been taken as a result of the Regulation 28 report having 
been issued. 

continued on page 2 
Chairman:  Deborah Jenkins 

Chief Executive: Siobhan McArdle 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Miss C Bailey 

3 May 2016 

Learning and reflection 

With  regard  to  the  concern  that  the  findings  of  the  abdominal  and  vaginal  examinations  did  not 
correlate, this was a significant learning point for the unit at the time of the incident.  Evidence was 
heard at the inquest from 
that she now understood why her clinical findings should 
have triggered further investigation and input from a senior midwife or obstetrician.  She went on to 
say  that,  if  faced  with  that  situation  again,  she  would  now  seek  input  from  a  senior  clinician  and 
would request a scan to confirm presentation. 

As you will see from the information set out below, determination of presentation will no longer be 
confirmed without the use of scanners in any event.  Nevertheless, important lessons were learned 
by the Trust on this point.  Had the inquest heard 
 evidence, it would be known that 
this incident was explored in detail in the department's risk management meetings, which are open 
to  all  members  of  clinical  staff.    Specifically,  the  obstetric  and  midwifery  risk  management  leads 
and unit managers regularly attend along with representatives from the neonatal and anaesthetic 
disciplines.  The minutes from each meeting are disseminated to all clinical staff along with a 'risky 
business' monthly bulletin that reinforces key points of learning. 

Through this medium, in September 2014, staff were reminded of the importance of seeking input 
from  senior  clinicians  at  an  early  stage  where  there  are  clinical  concerns.    This  was  followed  in 
October  2014  with  a  further  bulletin  regarding  the  importance  of  alerting  senior  clinicians  where 
there  are  concerns  about  clinical  findings.    Specifically  in  January  2015,  'Lincoln's  Rule'  was 
implemented,  urging  staff  to  adopt  a  low  threshold  when  considering  the  use  of  a  presentation 
scan where there is any doubt about clinical findings.  Lincoln's Rule also highlighted 4 red flags 
that should prompt further investigation, specifically drawing from the issues that were noted in this 
case.  These were: 

  Tooth paste meconium 
  A soft presenting part 
  On abdominal palpation presenting part feels deeply engaged, but on vaginal examination the 

presenting part is high 

  Location of the fetal heart is higher than you expect on auscultation 

In addition to local learning, the inquest would also have heard that the Trust is taking an integral 
part in the newly-developed Regional Maternity Patient Safety Network.  The principles behind this 
are set out in the statement of 
 at paragraph 48.  Had oral evidence been heard, she 
would  have  added  that  the  Network  is  now  established,  the  first  meeting  having  taken  place  in 
November 2015.  This case is on the agenda for discussion on the forthcoming Network meeting 
on 24 May, where lessons learned will be disseminated on a regional level. 

Additional training 

In  respect  of  the  concerns  around  appropriate  planning  for  dealing  with  breech  presentation,  the 
Trust  has  taken  various  measures  to  enhance  that  training  and  skills  base  around  breech 
deliveries, all of which would have been outlined by 

An upright breech study day took place on 21 November 2014 (as referred to at paragraph 30 of 
  statement),  which  was  open  to  all  doctors  and  midwives  within  the  Trust.    It  was 
  along  with  two  external  trainers,  both  of  whom  have  expert  knowledge 

operated  by 
within the field of breech deliveries.  The study day covered the following topics: 

Chief Executive: Siobhan McArdle 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Miss C Bailey 

3 May 2016 

  Mechanism of normal upright breech birth including hands on techniques 
  Counselling for informed consent 
  Training on when and how to assist delivery if labour does not progress normally 

An amended training programme to enhance vaginal breech delivery simulation sessions was also 
implemented in November 2014.  The session was updated to teach the practice of upright breech 
deliveries.  The session continues to run once every two weeks and there is a requirement for all 
clinical staff to attend the session on an annual basis, compliance with which is subject to audit. 
Policies and guidelines 

In  order  to  underpin  and  support  the  learning  and  training  around  appropriate  planning  and 
management of breech presentations, the Trust substantially updated its policies and guidance on 
this  issue.    The  first  amendment  was  implemented  in  October  2014  to  include  consultant 
attendance  at  breech  deliveries  and  to  highlight  the  'red  flags'  that  may  indicate  a  breech  (as 
outlined above in 'Lincoln's rule').  Had the inquest permitted evidence from 
 it would 
have been clear that the policy was further updated in January 2015.  A number of the changes to 
the  policy  are  directly  relevant  to  the  concerns  noted  in  the  Regulation  28  report  and  these  are 
summarised below. 

Lincoln's  rule  (as  set  out  above)  is  included  at  the  commencement  of  the  new  policy  to  highlight 
factors that would prompt suspicion that there is a breech presentation.  It goes on to highlight the 
importance of informed consent, noting that choices should be put to the woman, so that she can 
decide  which  risk  factors  are  most  acceptable  to  her.    The  policy  sets  out  common  risks  and 
benefits  to  the  mother  and  the  baby  associated  with  vaginal  breech  delivery  and  caesarean 
section, including situations where the breech is undiagnosed.  The purpose of this addition to the 
policy is to aid clinicians in their consent discussions with patients. 

The 'management in labour' section has been updated to note that any doubt in presentation of the 
baby  will  result  in  an  ultra  sound  scan  to  confirm  presentation.    It  goes  on  to  mandate  that  the 
consultant obstetrician, ST3 (or above) in obstetrics, the theatre team and the on-call anaesthetist 
are contacted.  Once the woman is fully dilated, the policy dictates that the consultant should be 
requested  to  attend  the  labour  ward  and  be  present  for  delivery,  unless  delivery  is  too  rapid  for 
them to arrive.  The Trust again reiterates that this policy, which has been in place for 16 months, 
goes over and above the requirements set out in the College guidance. 

The  'delivery'  section  of  the  policy  has  been  updated  to  reflect  the  additional  training  that  was 
delivered  on  methods/positions  for  delivery,  as  referred  to  in 
  statement  at 
paragraphs  28  to  30.    It  reminds  practitioners  that  the  CTG  will  not  be  reliable  after  the  baby  is 
delivered to the umbilicus and says that, instead the movement, tone, colour and cord should be 
assessed continually.  The manoeuvres for assisting/extracting a breech and the circumstances in 
which they should be used are set out in detail in the new guidance, with visual diagrams to assist.   
There  have  been  amendments  to  other  policies  to  take  account  of  the  new  procedures  around 
scanning, details of which are set out below. 

Scanning 

As  you  would  have  heard  from 
  nationally,  30%  of  breech  presentations  are 
undiagnosed when the mother arrives at hospital in labour.  This is because a breech presentation 
is  inherently  difficult  to  diagnose  on  palpation.    As  referred  to  at  paragraph  4  of 
statement,  scanning  of  women  on  admission  to  maternity  units  is  not  within  national  guidelines.  
There are not enough resources on a national level to implement such a policy.  Resource issues 
not only include the availability of equipment but also the training and competency maintenance of 
staff  to  carry  out  and  interpret  the  imaging.    The  Trust  position  remains  that  any  changes  on  a 

Chief Executive: Siobhan McArdle 

 
 
 
 
 
 
 
 
 
 
 
 
 
 Miss C Bailey 

3 May 2016 

national level in the policies around the scanning of women on arrival at maternity units would need 
to  be  considered  and  addressed  by  NICE  or  the  Department  of  Health  due  to  the  resource 
implications  that  it  would  have  for  the  NHS  as  a  whole.    For  the  avoidance  of  doubt,  the  steps 
taken by the Trust far in advance of the Regulation 28 report, which go beyond national practice 
and expected standards, has only been possible because of significant funding secured from the 
Department of Health's capital fund for the prevention of avoidable harm in maternity care. 

Given the concerns set out in the Regulation 28 report, it is vital to bear in mind that adopting this 
policy  will  not  eliminate  situations  whereby  unplanned  vaginal  breech  deliveries  occur  as  this 
depends on how advanced the labour is when the mother first presents and receives her scan on 
arrival at hospital.  If, for example, a women presents at hospital fully dilated with the baby at the 
perineum, regardless of the availability of a scan, the only safe way to deliver the baby would be 
vaginally. 
Although the policies around scanning at South Tees were in accordance with NICE guidelines, the 
Trust could see the benefit of introducing scanning in the early stages of labour.  Many months in 
advance  of  this  inquest,  the  Trust  set  out  a  framework  for  introducing  this  practice.  Had 
 statement been admitted into the record, the inquest would have heard details of this 
implementation  programme  as  set  out  in  paragraphs  5  and  6.    Had  the  Trust  been  permitted  to 
,  the  inquest  would  have  heard  how  far  this  implementation 
take  oral  evidence  from 
plan has developed to date.  Details of the progress of this plan are set out below. 

The aim of the programme, as set out in September 2015, was to ensure that all midwives have 
the  ability  to  perform  abdominal  scans  to  determine  the  presentation  of  the  baby  at  the  onset  of 
labour  or  on  induction  of  labour,  with  a  view  to  reducing  the  risk  of  undiagnosed  breech 
presentations.  For this purpose, 8 hand-held ultra sound scanners were purchased and distributed 
to the maternity wards across the Trust in April 2016. 

All  midwives  working  in  areas  where  there  is  induction  of  labour  or  admissions  of  women 
suspected to be in labour are to be trained in the technique of scanning for presentation by June 
2016.    Approximately  50  midwives  have  commenced  and  in  fact  almost  completed  their  training, 
which commenced in September 2015.  Midwives have been trained in the skill of carrying out and 
interpreting the results of a presentation scan using the equipment that was already available on 
the  unit.    Now  that  the  additional  handheld  machines  are available,  staff  are  being  trained  in the 
practical  use  of  the  scanner,  although  skill  in  clinical  interpretation  of  the  scan  is  transferrable  to 
the new machines. 

The  inquest  would  have  heard  that  a  Standard  Operating  Procedure  (SOP)  for  presentation 
scanning  was  implemented  in  March  2016,  the  details  of  which  are  set  out  below.    Currently,  all 
high and low risk women who are admitted for induction of labour have a presentation scan.  This 
has been the case since September 2015.  By June 2016, when all training will be completed, the 
SOP will apply to all women who are admitted in labour or who are suspected to be in labour.  The 
SOP sets out the following: 

  All women admitted will have an abdominal examination to determine the presenting part. 
  All women who are admitted for induction of labour are to have a presentation scan prior to the 
first dose of prostin or artificial rupture of membranes. The scan is to be repeated if a second 
cycle of medication is required. 

  All women who are admitted in labour or suspected to be in labour are to have a presentation 

scan, ideally prior to, or if not, following vaginal examination. 

  All midwives are to be trained in presentation scanning using the following programme 

  Witness one presentation scan 
  Manage 10 cases under the direct supervision  
  Final scan to be signed off for certification 

Chief Executive: Siobhan McArdle 

 
 
 
 
 
 
 
 
 
 Miss C Bailey 

3 May 2016 

  The skills maintenance programme is as follows: 

  Evidence of 10 scans every 12 months are to be presented at the Supervisor of Midwives 

 

and Staff Development Review  
If  skills  are  not  maintained  over  a  12  month  period,  5  further  scans  with  supervision  are 
required prior to further certification 

Currently,  the  findings  from  the  scan  results  are  documented  in  the  patient's  notes.    From  June 
2016,  the  partogram  (a  composite graphical  record  of  key maternal  and  fetal  data during  labour) 
will have a specific section for documenting presentation scan results. 

The  relevant  guidelines  to  accompany  Trust  policy  on  the  first  stage  of  labour  and  induction  of 
labour  were  updated  in  March  2016  to  reflect  the  requirement  for  presentation  scanning.  
Furthermore,  the  information  around  presentation  scanning  available  to  women  via  the  Trust 
website will be updated to reflect the new policy on this issue.  

Conclusion 

All  of  the  above  actions  are  subject  to  continued  audit  and  review,  the  Trust  being  committed  to 
continued  learning  and  development  of  practices  and  procedures.    We  trust  that  the  actions 
outlined  above,  which  we  reiterate  were  in  place  prior  to  the  hearing,  are  not  only  sufficient  to 
alleviate  the  concerns  set  out  in  the  Regulation  28  report,  but  also  demonstrate  that  the  steps 
taken  to  improve  patient  safety  outcomes  as  a  result  of  this  case  go  beyond  national  clinical 
practice guidelines and standards. 

Yours sincerely 

Siobhan McArdle 
Chief Executive 

Chairman:  Deborah Jenkins 

Chief Executive: Siobhan McArdle