Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0158, written 20 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 | 20 Apr 2016 |
|---|---|
| Reference | 2016-0158 |
| Deceased | Angus West |
| Coroner | David Hinchliff |
| Coroner area | West Yorkshire (Eastern) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
ANNEX A
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
NOTE: This form is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. Medical Director of the York Teaching Hospitals NHS Foundation Trust
1 CORONER
! am David Hinchliff, Senior Coroner, for the Coroner area of West Yorkshire (Eastern)
2 | 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.
3 | INVESTIGATION and INQUEST
On 20" February 2015 | commenced an investigation into the death of Angus Jonathan
Labofski WEST aged 27 days. The investigation concluded at the end of the Inquest on
4* April 2016. The conclusion of the Inquest was Natural Causes, the cause of death
being 1(a) Hypoxic-ischaemic encephalopathy
4 | CIRCUMSTANCES OF THE DEATH
Angus Jonathan Labofski West was born at York District Hospital on 24m January 2015.
It became apparent that he may have brain damage which necessitated him uitimately
being transferred to the Neonatal Unit at The General Infirmary, Leeds, where he was
noted to be perfect before he became unwell and had no infections and for reasons
which are not clear, he became asphyxiated which led to him suffering severe hypoxic-
ischaemic encephalopathy which caused his death to be confirmed at Martin House
Children’s Hospice, Boston Spa, at 1424 hours on 20" February 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. —
[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) After the baby was born the placenta was not retained. Within a short time after
his birth he became unwell and despite all efforts his death was confirmed. It
was likely that a post mortem examination would be needed to determine the
cause of death. It would have been of assistance to the Pathologist to be able to
examine the placenta to show the possibility of a toxoplasmosis infection; to
establish if relevant the possibility of placental abruption and to establish if the
umbilical cord was kinked, trapped or in any way damaged which could have
caused or contributed to the death. | therefore recommend and request that
when it is foreseeable that at birth or shortly thereafter, the baby’s condition is
poor and is deteriorating which may lead to death, then the placenta and all its
appendages should be retained and be made available to the Pathologist for
further examination.
ACTION SHOULD BE TAKEN
Although the absence of the placenta at the time of post mortem examination will not
prevent future deaths it would be useful and desirable for the placenta to be examined
so that greater understanding can be achieved as to the processes leading to death. |
believe that your organisation has 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 16" June 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, the Royal College of Obstetricians
and Gynaecologists and to the Local Safeguarding Board. | have also sent it to the
Royal College of Midwifes, who may find it useful or of interest.
{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.
20" April 2016 Signed: ; 7
Senior Coron
2 responses 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 ROYAL COLLEGE OF : MIDWIVES Promoting - Supporting - Influencing clo lS ANGUS west a 27 MAY aap 26 May 2016 Mr David Hinchliff Senior Coroner West Yorkshire (Eastern) Coroner’s Office and Court 71 Northgate Wakefield WF1 3BS Dear Mr Hinchliffe, Thank you for your letter of 25 April 2016, and | do apologise for the delay in replying. | have taken the opportunity to seek the views of the RCM Advisory Forum as they are very helpful with strategic issues and of course they all practice within the context of contemporary midwifery practice. My response is therefore based on this information and my own experience of best practice across the UK. For information purposes the forum is comprised of midwives, students and maternity support workers who are clinically working within maternity services across the UK. Given the view of the RCM Advisory forum and what | believe to be best practice, | entirely agree with your recommendations to this particular NHS Trust. | would have expected that for any baby compromised in labour or requiring transfer to the Neonatal Unit the advice would be to have the placenta retained and safely stored and therefore available should there be a demise in the baby and a need for a post mortem examination at a future point in time. For further information | have included below information regarding current practice, disposal and reasons to store placenta within the NHS as it stands today. Current placental disposal following the majority of births is as follows All placentas are disposed of post- delivery by sealing them in a sharps guard anatomical plastic bag and transferred into a permanently sealed plastic pot for incineration following examination by the midwife or clinician post birth. Exceptions to the above: retaining the placenta for pathology purposes Stillbirth Late fetal loss Significant fetal compromise in labour Baby with a low Apgar score Baby transferred to Neonatal Unit Baby who has had extensive resuscitation Baby with abnormalities Prematurity Some maternity units keep and examine placenta in the following cases Intra uterine growth restriction i.e. birthweight below the 3" centile Placental abruption Rhesus isoimmunisation Morbidly adherent placenta Multiple births Abnormal placental shape Two vessel cord Prolonged rupture of membranes >36 hours Maternal group B streptococcus Pre eclampsia/maternal hypertension Maternal substance misuse Gestational diabetes Maternal coagulopathy In addition it is worth noting that some women do take care of their own placenta by taking them home from the maternity unit or birth centre. On a final note one of the biggest challenges within maternity care is safe storage of placenta should we hold large numbers in case of neonatal deterioration. | do hope this information is helpful but please do contact me if you require any further information. Yours sincerely, Professor Cathy Warwick, CBE Chief Executive
York Teaching Hospital INHS| NHS Foundation Trust Medical Governance The York Hospital Wigginton Road York YO31 8HE 01904 631313 | Medical Director 8° June 2016 Mr D Hinchliff Senior Coroner West Yorkshire (Eastern) Coroner’s Office and Court 71 Northgate Wakefield WF1 3BS Dear Mr Hinchliff Re: Inquest Touching the Death of Angus Jonathan Labofski West (Deceased) Thank you for your recent letter regarding the findings in this inquest and the Regulation 28 Report to Prevent Future Deaths which you have issued as a consequence of these findings. As indicated in my acknowledgement of this notification, | have shared this with the Clinical Director for Obstetrics and Gynaecology and the Risk Management team. The Trust have liaised with The Royal College of Obstetrics and Gynaecology and neighbouring Trusts (principally Leeds Teaching Hospitals NHS Trust) seeking advice on this matter. | am also grateful for the copy of the response from the Royal College of Midwives which you have forwarded. As a consequence of the tragic outcome in this case and the inquest findings we undertake to institute the following standard operating procedure in respect to retention of placenta following childbirth. Points a) and b) are current standard practice and the remaining points are to be instituted by September 1°' 2016. a) The placenta and all its appendices are routinely inspected at all deliveries. b) All placentas from stillborn infants or intra partum deaths are sent for detailed histopathology examination at our neighbouring trust (The Leeds Teaching Hospital NHS Trust), with necessary consent from the parents. c) All placentas and their appendices from all live births are bagged, labelled and dated and kept refrigerated on labour ward for a period of 24 hours. e If the baby is born in good condition and remains well and there are no further concerns, the placenta will be disposed of, with the appropriate permission from the mother, after 24hrs. e Ifthe baby is born in poor condition, or extremely preterm, or deteriorates soon after birth (within 24 hours) then we intend that the placenta will be retained for further storage and will be sent to the histopathology department locally at York for a period of 30 days. lf during this time the baby goes on to die, at that point the (stored) placenta with its appendices will be sent for formal histopathology examination at Leeds. This will either be along with the infant post- mortem request or separate from this, depending on the necessary consent from the parents. | hope that this undertaking alleviates the concerns raised during the recent inquest and reassures you that all reasonable steps have been taken to prevent a similar occurrence in the future. | would be happy to write to you again after the proposed implementation date to confirm that the Trust has complied with these undertakings. Should you require any further information do not hesitate to contact myself or | EEE Ocputy Medical Director. Yours sincerely 7A Medical Director & Responsible Officer Copy to PY Deputy Medical Director, York Teaching Hospital EEE Clinical Director, Obstetrics & Gynaecology, York Teaching Hospital ee Lead Clinician for Histopathology, York Teaching Hospital BE Chief Medical Officer, The Leeds Teaching Hospitals NHS Trust
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