Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0125, written 4 Apr 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Apr 2016 |
|---|---|
| Reference | 2016-0125 |
| Deceased | Kristian Jaworski |
| Coroner | Andrew Walker |
| Coroner area | London (North) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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Her Majesty's Coroner for the 29 Wood Street, Northern District of Greater London —Bamet ENS 486 ey, (Harrow, Brent, Barnet, Haringey and Enfield) Telephone REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO Department of Health, Health and Wellbeing Richmond House, 79 Whitehall, London, SW1A 2NS CORONER lam Andrew Walker, senior coroner, for the coroner area of Northern District of Greater London CORONER'S LEGAL POWERS | 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. INVESTIGATION and INQUEST On the 9" July 2075 | opened an investigation touching the death of Kristian Andrew Jaworski , 5 days old. The inquest concluded on the 21" March 2016 The conclusion of the inquest was "Complications of delivery’, the medical case of death was 1a Asphixia | as a consequence of prolonged and extended instrumental delivery. CIRCUMSTANCES OF THE DEATH On the 20" September 2012 a :: 16.18 was delivered of a son by forceps. a .:; told that she had a narrow birth canal at the time that her first child was born and was told to ask for a caesarian section were she to have a further child it is likely that this was said. It is likely that the obstetrician who delivered the first child did tel] firstly that the birth canal was narrow and secondly that was told to ask for a caesarian section on the next occasion. BE «<<a notes made no reference to these matters. On the 18" May 2015 vnen planning for the delivery of her next child raised with a Consultant Obstetrician that during her first birth she had been described as having a narrow birth canal and that the birth had been traumatic for North London Coroners Court, Her Majesty's Coroner for the Northern District of Greater London (Harrow, Brent, Barnet, Haringey and Enfield) her ,she had some decelerations and then episiotomy and a 2" degree tear and was concerned about a similar problem and Ec that she was told to ask for a caesarean section . A plan was made for vaginal delivery with the option of an emergency caesarian section and there matters rested. On the 27" June 2015 attended North Middlesex = Triage following the spontaneous rupture of her membranes at 16.30. was examined and discharged home. At 23.45 P| returned and was again discharged home. At 1.40 hrs on the 28" June 201 SEE returned to the Triage at North Middlesex Hospital and was transferred to the labour ward at 2.10 hrs. At 4.30 the Registrar was summoned to review fetal heart rate and decelerations. At 4.43 a fetal blood sample was taken and was borderline abnormal. At 5.00 the progress was discussed with the Registrar and the Consultant Obstetrician agreed with the plan to take to theatre. The Consultant Obstetrician believed that the purpose of taking to theatre was to deliver the child by caesarean section. During this period there continued to be an abnormal CTG trace but given the normal fetal blood samples this was reassuring. Tn theatre the Registrar made an assessment of P| birth canal and reached the conclusion trial of instruments would be appropriate. At 5.55 delivery was attempted by Ventouse and there was descent with each of 3 pulls. At 6.12 a decision was taken by Registrar to switch to forceps and a fourth pull resulted in no descent. A more junior doctor present was asked to givea5" pull again with no decent. A fetal bradycardia with a heart rate below 100 was noted and the decision taken to abandon instrumental delivery. A category | caesarean section was then necessary and was started using an epidural and then a general anaesthetic. Kristian was born at 6.39 with poor Apgar scores and was soon transferred to University College Hospital where he died on the 3 July 2015. The cause of death is likely to have been Asphyxia as a consequence of prolonged and extended instrumental delivery. Northern District of Greater London (Harrow, Brent, Barnet, Haringey and Enfield) 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. — To the Department of Health That there was a presumption in favour of vaginal delivery based partly of cost that needed to be rebutted. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you [AND/OR your organisation] have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by Tuesday 31% May 2016. |, 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons;- Representatives of the family 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. 4” April 2016. (
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.
From Ben Gummer MP Parliamentary Under Secretary of State for Care Quality Department Record tt of Health tehal POC 1028108 SWIA 2NS Tel: 020 7210 4850 Mr Andrew Walker Senior Coroner North London Coroner’s Court 29 Wood Street Barnet ENS 4BE (~ May 2016 ne, MW (tu Thank you for your letter of 4" April 2016 following the inquest into the death of Kristian Jaworski. I was extremely sorry to hear of Kristian’s death and wish to extend my sincere condolences to his family. You are concerned that, in this case, there was a presumption in favour of vaginal delivery based partly on cost. In addition, I note that there appears to have been a failure of several doctors involved in the care of Kristian’s mother to make a recorded note of her biological condition (i.e. narrow birth canal), the problems this had caused with a previous delivery and the advice for her to request a caesarean for any future births. You have also raised concern about doctors giving a fifth pull with forceps rather than switching to a caesarean section for delivery of the baby. My officials have contacted the Royal College of Obstetrics and Gynaecology (RCOG) for advice about the use of instruments during vaginal delivery. RCOG advise that it’s Green Top Guideline No. 26 on Operative Vaginal Delivery (published in 2011 and reviewed in 2014) states that one of the prerequisites for operative vaginal delivery is that the ‘pelvis is deemed adequate’. The guideline also covers when operative vaginal delivery should be abandoned. Section 5.4 says that ‘operative vaginal delivery should not be attempted unless the criteria for safe delivery have been met. Operative vaginal delivery should be abandoned where there is no evidence of progressive descent with moderate traction during each contraction or where delivery is not imminent following three contractions of a correctly applied instrument by an experienced operator’. I note that, in this case, a fourth and fifth pull using forceps was attempted — this was clearly not in line with the RCOG guidance. There is a sound basis for the RCOG advice. It is known that the sequential use of instruments is associated with an increased risk of trauma to the infant. Nevertheless, the operator still needs to weigh up the risks of a caesarean section following failed vacuum extraction with the risks of forceps delivery following failed vacuum extraction. Obstetricians should also be aware of increased neonatal morbidity with failed operative vaginal delivery and/or sequential use of instruments and should inform the neonatologist when this occurs to ensure appropriate management of the baby. The RCOG guidance is also clear that ‘the sequential use of instruments should not be attempted by an inexperienced operator without direct supervision and should be avoided if possible’. The full RCOG guidance is available at: hitps://www.rcog.org.uk/globalassets/documents/guidelines/gtg_ 26.pdf I am unable to comment on why a caesarean delivery was not attempted at an earlier opportunity in this case or whether that decision was based in any way on cost — this is clearly something that the North Middlesex University Hospital NHS Trust needs to consider. I will ensure that a copy of your letter and this reply are sent to the Trust to give them the opportunity to respond to your concern. I can advise however, that there is clinical guidance for health professionals around the use of caesarean section (CS) which has been produced by the National Institute for Clinical Excellence (NICE). Treatment decisions in maternity care should always be made by clinicians in full consultation with women and should be based on a woman’s individual clinical needs, in line with these guidelines. You may wish to note that part of the guideline covers the economic issues relating to CS and includes an analysis of the costs of different methods of birth (both planned and unplanned) and care options. The issue of cost-effectiveness is discussed and recommendations are made that represent a cost-effective use of healthcare resources. The full guidance is available at: https://www.nice.org.uk/guidance/cg132/evidence/full-guideline-184810861 ae Department of Health I will now turn to the issue of clinical record keeping, as there appears to have been a failure of several doctors to make adequate recorded notes relating to the biological condition of Kristian’s mother, the problems this had caused with a previous delivery and the advice for her to request a caesarean for any future births. Whilst I cannot comment personally on the reasons behind this lack of note taking, I would like to point out that the General Medical Council (GMC) has issued clear guidance about record keeping as part of their Good Medical Practice guidance. I’ve pasted relevant paragraphs 19 -21 below which include advice concerning clinical records: Record your work clearly, accurately and legibly 19. Documents you make (including clinical records) to formally record your work must be clear, accurate and legible. You should make records at the same time as the events you are recording or as soon as possible afterwards. 20. You must keep records that contain personal information about patients, colleagues or others securely, and in line with any data protection requirements. 21, Clinical records should include: a. relevant clinical findings b. the decisions made and actions agreed, and who is making the decisions and agreeing the actions c. the information given to patients d. any drugs prescribed or other investigation or treatment e. who is making the record and when. T hope that this reply is felpful and I am grateful to you for bringing the circumstances of Kristian’s death to gur Attention. (2) BEN GUMMER
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