Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0192, written 11 Mar 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Mar 2016 |
|---|---|
| Reference | 2016-0192 |
| Deceased | Amelia Calvo |
| Coroner | Fiona Borrill |
| Coroner area | Manchester City |
| Category | Child Death (from 2015) · Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS This report is made under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. Recipients This report is being set to: e Department of Health Coroner | am Fiona Borrill, HM Area Coroner for the area of Manchester City. 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 31 March 2014 | commenced an investigation into the death of Amelia Celestine Calvo, aged 1 day. The investigation concluded at the end of the inquest on 11 March 2016. The cause of death was found to be: ja Multi organ failure. Disseminated intravascular coagulation 1b Hypovolemic shock 1c Haemorrhage during procedure 2 Trisomy 18 The recorded a Narrative Conclusion: Natura! causes contributed to by a minimisation of the risk of loss of intubation by not guarding the endotracheal tube in a ventilated baby and a breakdown in communication between medical staff in theatre on 28 March 2014. Circumstances of death The deceased was born at 31 weeks gestation on 27th March 2014 at 20:23 at St Mary's Hospital as a twin delivery weighing 1.15kg. She was subsequently diagnosed with Edwards Syndrome, a life limiting condition. She had poor respiratory effort and was successfully intubated at the fourth attempt at 12 minutes of age. She was transferred to the neonatal intensive care unit and remained ventilated. Cardiac anomalies were diagnosed by ultra sound scan. Chest x-ray revealed that the nasogastric tube looped in a blind ending oesophagus and a diagnosis of oesophageal atresia with tracheo-oesophageal fistula was confirmed. To be treated for this required urgent surgery to ligate the tracheo-oesophageal fistula, and this procedure was listed for the afternoon of 28th March 2014. The deceased was safely transferred to theatre at the Royal Manchester Children's Hospital at 13:45 on 28th March 2014. In theatre and following a team briefing, at which the Paediatric Surgeon was absent, the Paediatric Anaesthetist, following arrival of the Paediatric Surgeon, performed a laryngoscopy which confirmed a grade 4 airway and this was communicated to the theatre team, The evidence leads me to find that thereafter there was a breakdown in communication between medical staff, as the Paediatric Surgeon decided to proceed to examine the larynx himself and the Paediatric Anaesthetist understood that there would be a further discussion as to whether to proceed with a rigid bronchoscopy or alternatively a flexible bronchoscopy and seek further specialist advice prior to surgery being undertaken. Despite the fact that the endotracheal tube was not guarded by an anaesthetist or the deceased prepared for a laryngoscopy, the Paediatric Surgeon inserted a bronchoscope and laryngoscope into the deceased's mouth to view the back of the throat, the endotracheal tube became dislodged and the deceased subsequently developed severe problems with a difficult airway, pneumothoraces and bleeding. Despite all resuscitative measures and interventions, she deteriorated and died at 18:01 on 28th March 2014. 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 inquest, | heard evidence from Po Consultant Neonatologist, the independent expert instructed by the court that the grading system used by anaesthetists to assess a patient's throat prior to carrying out a laryngoscopy and assessment generally, namely the view being classified as follows: Grade |: Complete glottis visible Grade II: Anterior glottis not seen Grade III: Epiglottis seen, but not glottis Grade IV: Epiglottis not seen is not a classification that is generally used in neonatal practice. oo;°0 ° advised that in fact this classification was ‘rarely’ used in neonatal practice and that there were discussions currently being undertaken as to creating a joint anaesthetic/neonatal guideline. In Amelia’s case, the issue as to whether or not there was a ‘difficult/dangerous’ airway was not handed over by the neonatologists to the paediatric anaesthetist prior to the surgery on 28 March 2014 as the neonatologists did not consider 4 attempts at intubation at birth to be indicative of a difficult airway. HE aciditionally stated that in his Trust discussions were taking place in the neonatology department with regard to using this classification system, but there is no national guideline to this effect. Action should be taken In my opinion action should be taken to prevent future deaths and | believe your organisation has the power to take such action. 1. | require to be advised as to whether the Department of Health is considering, along with the appropriate Royal Colleges, the introduction of a guideline to ensure clarity of assessment of the airway. Your response You are under a duty to respond to this report within 56 days of the date of this report, namely by 15 July 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: | 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. Ruan F Borrill Date H.M. Area Coroner — Manchester City area
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.
Central Manchester University Hospitals INHS| NHS Foundation Trust Trust Headquarters Cobbett House Manchester Royal Infirmary Manchester M13 9WL Tel No: 0161 276 4755 Fax No: 0161 272 6931 29" November 2016 Ms F Borrill HM Area Coroner Manchester City Area HM Coroner's Office PO Box 532 Manchester Town Hall Albert Square Manchester M60 2LA —\ [PAs RECE IVED 02 220 206 sen eT Dear Ms Borrill Re: Inquest touching the death of Amelia Calvo | am writing in response to your letters of 18 May and 26 October 2016 regarding this matter. | would like to apologise for the delay in responding to your initial letter. Point 1 Request for advice on how competing requirements to attend meetings at lunchtime and be present for Team Briefings for afternoon surgery can be put into effect so that patient safety is not compromised Work has been undertaken in RMCH to ensure clinical engagement with the Team Brief: s The list used within the Team Brief was revised to address potential gaps in the original Brief and piloted. This work was clinically led and was rolled out to the CEPOD Theatre in June 2016 and is now used in all RMCH Theatres. This includes: o an Introductions Board has been implemented which includes a check of the box on the Team Brief board supporting the presence of all involved staff including the Lead Operating Surgeon and Anaesthetist o increased relevance for clinical staff with changed order of items within the Team Brief (surgical and anaesthetic plan are now discussed at the start of the Team Brief) and more room on the board for the ‘Any Problems’ section . Operating Surgeon for the procedure; if the Operating Surgeon is not present the patient will not be sent for. Within working hours the presence of key staff (including the Operating Surgeon) has improved; out of hours (nights and weekends, when the Operating Surgeon may not be resident on the hospital site) issues can arise with the attendance of the Operating Surgeon; advice is that the patient must not be sent for until the Team Brief has taken place with the Operating Surgeon present The team who have led on the above changes continue to review this on a regular basis. Point 2 Re ere caused considerable distress by the use of the word ‘outcome’ in the High Level Investigation report. HM Area Coroner was told this referred to the fact that Amelia would have died in the future in any event of the, at that stage, undiagnosed Edwards Syndrome but EE one of the investigation team, did concede that the use of the word ‘outcome’ was insensitive in all the circumstances Our understanding, through discussion and following receipt of a letter of complaint from Amelia’s parents (dated 13.06.16), was that the concern related to the following wording in the conclusion of the report: ‘These deficiencies should be urgently addressed in order to avoid recurrence of these events in future, in a situation which is likely to have more clinical significance’ HE complaint stated ‘no parent should have to read that their child is not clinically significant’. In the response Tim complaint (dated 30.08.16), it was acknowledged that the phraseology was insensitive and that we were deeply sorry that this was not identified by anyone involved in the production and checking of the HLI report. Point 3 Evidence that Mortality and Morbidity team meetings in the Paediatric Anaesthetic Department were not minuted. It is understood that those meetings are now minuted and the minutes circulated to clinicians. Request for confirmation of this From January 2017, the Paediatric Anaesthetic Department’s discussion of Mortality and Morbidity will take place as part of the agenda within the Trust wide Audit and Clinical Effectiveness (ACE) Days. These dates are planned in —_— le by the cancellation of elective activity. , Clinical Lead — Theatres and Anaesthesia, has confirmed that when mortality and morbidity cases are discussed, summary notes will be provided to capture responses, recommendations, action plans or outcomes. Anaesthetic deaths are rare, and the ACE day is considered an appropriate forum for a departmental discussion of mortality and morbidity. It is important to highlight that in addition, Royal Manchester Children’s Hospital has a well- established Mortality Group whereby the final episode of care is reviewed by a Consuitant who was not invoived in the patient’s care. These meetings are minuted and the minutes are circulated (to reviewing members and Consultant medical staff identified as involved during the patient’s final episode of care at RMCHh). If you need any further information, please do not hesitate to contact me. Yours sincerely WB, Sir Michael Deegan Chief Executive
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