Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0251, written 15 Jul 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 15 Jul 2016 |
|---|---|
| Reference | 2016-0251 |
| Deceased | Leilani Chute |
| Coroner | Bridget Dolan QC |
| Coroner area | West Sussex |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Child Death (from 2015) |
| Organisation named | Western Sussex Hospitals NHS Foundation Trust |
| 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 BEING SENT TO: 1. The Chief Executive, Western Sussex Hospitals NHS Foundation Trust 2. Chief of Service for Women and Children’s Division, Western Sussex Hospitals NHS Foundation Trust. St Richard’s Hospital, Spitalfield Lane, Chichester, West Sussex PO19 6SE CORONER Iam Bridget Dolan QC, assistant coroner, for the coroner area of West Sussex 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. INVESTIGATION and INQUEST On 6 August 2015 the Senior Coroner commenced an investigation into the death of Miss Leilani Chute. The investigation concluded at the end of the inquest on 30 June 2016. The conclusion of the inquest was that the medical cause of death was: 1a hypoxic brain injury and 1b umbilical cord occlusion. I concluded that Leilani Chute died shortly after her birth from natural causes, however the evidence also led me to find that had the failure to progress earlier in labour been reported to the consultant, the birth plan would have been to go directly to a Caesarean Section with delivery by about 14:20 - thereby avoiding the final cord occlusion and acute hypoxia. CIRCUMSTANCES OF THE DEATH 1. On the late evening of 4 August following syntocinon augmentation Leilani’s mother, Mrs Chute, was in active labour. From almost the outset a series of assessments with a fetal scalp electrode in place noted, or should have noted, that the CTG tracing was ‘suspicious’ meaning that there was at least one non-reassuring feature. 2. By 13.40 the following day the cervix was still not fully dilated and had the consultant obstetrician known or been informed of this he would have described this as a ‘failure to progress’ at the first stage of labour and so advised that a Caesarean Section (‘CS’) should be carried out. Furthermore, the baby’s head was in an unfavourable position deflexed, and the baby was lying in an OP position and still mid cavity. Delivery could have been achieved by CS in around 30 minutes. 3. What the consultant obstetrician was not made aware of, however, was that the SHO had tried to manually push the cervix back at 12.30 and the registrar had also done this at 13.40 and, on the latter occasion, had thereby achieved ‘full’ dilation. This is not a technique that was endorsed by the consultant obstetrician. The independent expert obstetrician, | described it as something not in any textbook and also futile as it did not actually achieve the progression of an arrested labour. 4. It was against this background that a plan was formed to allow F a further half an hour of pushing and if that did not achieve delivery to then move on to a trial of instrumental delivery in theatre followed by CS if necessary. 5. When the plan including instrumental trial was relayed . she said she would prefer not to have forceps used at delivery. There was an ensuing discussion with the registrar which, as he accepted, focussed on the risks of caesarean section and on the benefits of vaginal delivery was not told that her baby was lying in an OP position and that the risks of failure of instrumental delivery were higher with an OP baby. Furthermore, as the registrar accepted, when she had emphasised to him that she “Just wanted what was best for her baby” then, given this clear statement, he should have, but did not, tell her that to go directly to a CS presented less risk to the baby. 6. Wha took from the discussion was that it was too risky to have a CS and it was in this context that she agreed to (and signed the form consenting to) a trial in theatre of instrumental delivery before any CS. 7. The trial of instrumental delivery was not successful and so at around 14.32 the procedure was abandoned and preparations for a CS were made. Leilani was delivered at 14.46. Sadly she was in a moribund condition, in a state of terminal bradycardia and with no other signs of life. 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 citcumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. — (1) That the practice of manually pushing back the cervix was one adopted by two junior doctors. This practice was not in accordance with standard training and was conducted without the knowledge of the consultant; (2) That the manner in which consent was sought from women in labour when there was a choice to be made between attempted instrumental delivery and going straight to a CS did not appear to provide them with the relevant facts in order to come to an informed choice, but presented those facts that favoured the doctot’s pteferred approach to management. That neither of the above matters had been identified as a “Care and Service Delivery problem” by the Trust’s Root Cause Analysis investigation and hence no steps had been taken by the Trust to address these issues. 3 ~ ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisations 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 16 September 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. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Petsons: a parents of Leilani Chute) ~~ Tam 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. 15 July 2016 pp Bridget Dolan
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.
Western Sussex Hospitals INHS NHS Foundation Trust St Richard’s Hospital Spitalfield Lane Chichester West Sussex PO19 6SE Fax: 01243 531269 | 4 SEP 2016 www.westernsussexhospitals.nhs.uk 12 September 2016 Ms B Dolan QC Assistant Coroner for the County of West Sussex Coroner's Office West Sussex Record Office Orchard Street Chichester West Sussex PO19 1DD Dear Ms Dolan RE: Regulation 28 Report to Prevent Future Deaths — Baby Leilani CHUTE | write to formally acknowledge receipt of the Regulation 28 report to Prevent Future Deaths and to respond to your three matters of concern. Please be assured that the specific issues have been considered in depth by the clinical leadership team, explored further at a very well attended governance event dedicated to these issues and that an action plan is being implemented. The concerns are addressed individually below. 1. That the practice of manually pushing back the cervix was one adopted by two junior doctors. The practice was not in accordance with standard training and was conducted without the knowledge of the consultant. i. | Audit of current practice An audit of instrumental deliveries undertaken in the operating theatre was completed in August to establish whether manually pushing back the cervix is part of our clinical practice. Case notes from 641 patients from the Chichester and Worthing sites from the last 12 months were reviewed. The practice of pushing back the anterior lip of the cervix was used infrequently and found in 15 women most of whom were primiparous. The procedure was usually undertaken by middle grade doctors rather than midwives or consultants. The vast majority of these women proceeded to deliver vaginally. No harm was identified from the practice. Feedback from the audit will now take place at both departmental level and for the individuals concerned. ii. | Feedback for the two individuals involved in baby LC’s delivery who used the practice of manually pushing back the cervix Initial feedback with the supervising consultants has taken place for both the trainee doctors who used this procedure prior to them leaving the Trust. Further formal meetings are scheduled to take place that include their educational supervisors from their time at WSHT and their new supervisors. Your concerns will also be shared with the deanery to ensure there is wider learning. iii. | Policy and guidance A statement has been circulated by email to the medical and midwifery staff highlighting the Trust position that manually pushing back the cervix is not an acceptable practice. This has also been highlighted at the maternity safety huddles. Safety huddles are daily meetings that take place on each ward to raise safety issues with staff and anticipate risk in daily workload. In addition, local guidelines have been amended to state clearly that pushing back the cervix is not acceptable practice. 2. That the manner in which consent was sought from women in labour where there was a choice to be made between attempted instrumental delivery and going straight to CS did not appear to provide them with the relevant facts in order to come to an informed choice, but presented those facts that favoured the doctors preferred approach to management. i. Policy and guidance In view of your concerns the Trust has reviewed both the overall Trust guidance and the relevant specialty guidance on consent. The existing overall Trust guidance gives clear guidance on informed patient choice and fully reflects the implications of the recent Montgomery judgment. Work is underway to strengthen the Trust's specialty guidance on instrumental delivery and caesarean section to fully reflect Royal College of Obstetrics and Gynaecology (RCOG) guidelines on consent in these specific circumstances and places appropriate emphasis on informed patient choice. ii. Training The service has introduced a more in depth online training module for obstetric staff alongside the existing Trust mandatory annual online e-learning on consent. The recently introduced EIDO Healthcare online learning contains a specific module on consent in obstetrics and all obstetric and gynaecological medical staff are now required to undertake this training every three years. The uptake of training will be monitored by the Division and a link to the training is shown below. http://www.beinformedplus.com/ iii. Feedback and learning for the individuals involved in the consent process See item 1.ii. Reflection on the consent process has formed and will form part of these meetings with trainees. Other senior staff involved will use the appraisal process for reflection and learning. 3. That neither or the above items had been identified as a ‘Care and Service Delivery problem’ by the Trust’s Root Cause Analysis investigation and hence no steps had been taken by the Trust to address these issues. i. | Processes for planning investigations when perinatal deaths have occurred A review of existing processes for these investigations is underway using existing models of best practice from the RCOG and CQC with a half day governance meeting scheduled for October to consider any emerging proposals. The Trust governance team has also been asked to provide support for the division to ensure that RCA’s undertaken for Serious Incidents are rigorous and objective. From late 2017 it is anticipated the planned NHS England/Department of Health National Perinatal Mortality tool will become available and will be implemented at the Trust. The newly developed tool adopts a standardised approach for the investigation of perinatal deaths and will incorporate national reporting and learning. We hope that the above provides sufficient assurance that the Trust continues to strive to learn from Baby Leilani’s death. Yours sincerely Marianne Griffiths Chief Executive (signed for and on behalf of Marianne Griffiths, by Po Medical Director and acting Chief Executive)
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