Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0393, written 2 Nov 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 Nov 2016 |
|---|---|
| Reference | 2016-0393 |
| Deceased | Ivy Morris |
| Coroner | John Ellery |
| Coroner area | Shropshire, Telford and Wrekin |
| Category | Child Death (from 2015) · Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | The Shrewsbury and Telford Hospital NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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.) Mr Simon Wright
Chief Executive
Shrewsbury and Telford NHS Trust
Royal Shrewsbury Hospital
Mytton Oak Road
Shrewsbury
SY3 8XQ
CORONER
{ am John Penhale Ellery, Senior Coroner, for the coroner area of Shropshire, Telford &
Wrekin
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 6'* May 2016 | commenced an investigation into the death of Ivy Rebecca Morris
aged 4 months. The investigation concluded at the end of the inquest on 12th October
2016. The conclusion of the inquest was Ivy Morris died from natural causes where
death would have been prevented had appropriate monitoring taken place in the
second stage of labour. The second stage of labour was delayed which added to the
period of hypoxia and the severity of Ivy's hypoxic ischaemic brain injury at birth. As a
result of her avoidable injuries, lvy was vulnerable to bronchopneumonia, a condition
from which she suffered in the months following her birth. On 3 May 2016 Ivy collapsed
at home following an episode of bronchopneumonia and did not recover.
CIRCUMSTANCES OF THE DEATH
Ivy was born at the Princess Royal Hospital, Telford on the 15th December 2015
following complications at birth Ivy was born with limiting medical needs including
severe perinatal hypoxic ischaemic brain damage. Ivy had a prolonged stay in hospital
following her birth and on discharge home she required her feeds through a nasogastric
tube. On the 3rd May 2016 Ivy was at home 2¢ jaa ama
being cared for by her father [EEN During her feed witnessed Ivy
becoming unresponsive. He called for an ambulance and commenced resuscitation until
the arrival of the ambulance. Resuscitation was continued by the paramedics until
arrival at the Royal Shrewsbury Hospital where ivy was pronounced dead.
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} Foetal heart monitoring.
Ivy’s foetal heart rate ought to have been monitored and was not monitored.
In the second stage of labour the maternal heart rate was recorded on the
external CTG machine for the majority of (if not all) the time when the intent
was to monitor the foetal heart rate. The confounding factor was the similarity
of the heart rates at the commencement of the second stage. There were
opportunities and methodologies available to resolve this issue that were not
taken. There was evidence of potential error of this kind in the interpretation
of CTG traces being a known phenomenon.
(2) Failure to follow midwifery guidelines.
a. To confirm assessment of the CTG using the agreed assessment tool.
b. The need to request an obstetric review after 1 hour of active pushing.
c. The need to request an obstetric review for maternal tachycardia.
(3) Episiotomy.
infiltration took place which could have led to an episiotomy and delivery
within 10 minutes. There was unresolved evidence as to whether an
episiotomy was a planned event or a contingency which did not arise. There
was though evidence that the midwife who performed the infiltration had not
performed an episiotomy since qualification and wished to have support and
supervision should one become necessary. Whilst such support and
supervision may have been available in this case, in other this could lead to
delay.
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.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 28" December 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
| have sent a copy of my report to the Chief Coroner and to the following Interested
Persons, MHRA, Chief Executive NHS England, Head of the Royal College of
Obstetricians & Gynaecologist and Head of the Royal College of Midwives.
1am 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.
2°¢ November 2016 R. Ellery
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