Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0001, written 12 Jan 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 Jan 2017 |
|---|---|
| Reference | 2017-0001 |
| Deceased | Jennifer Clark |
| Coroner | Thomas Osborne |
| Coroner area | Bedfordshire and Luton |
| Category | 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.
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Thomas R Osborne
Senior Coroner for Bedfordshire and Luton
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
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THIS REPORT IS BEING SENT TO:
The Chief Executive |
| Watford General Hospital
| Vicarage Road
| Watford
. Hertfordshire
WD18 0HB
CORONER
‘Tam Thomas R Osborne, Senior Coroner for Bedfordshire and Luton
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CORONER’S LEGAL POWERS
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| I make this Report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2909 ;
| and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
http://www.legislation.gov. uk/ukpga/2009/25/schedule/5/paragraph/7
bttp:/www.legislation.gov. uk/uksi/2013/1629/part/7/made
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| INVESTIGATION and INQUEST
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On 6 October 2014 I commenced an investigation into the death of Jennifer Elisabeth |
| Lestajo CLARK aged 18 hours . The Investigation concluded at the end of the Inquest ;
on 10 January 2017. The Conclusion of the inquest was a “Narrative Conclusion’
_The deceased was born on 24 September 2014 at 00:54 hours at Watford General |
Hospital At the birth there was a failure to carry out a detailed assessment as to ber |
condition and a failure to monitor her continuously until at 01:26 hours it was recognized |
that she had coliapsed: there was a further failure te escalate her case quickly She was |
transferred to the Luton & Dunstable Hospital and died at 18:25 hours from a massive ;
pulmonary haemorrhage. The failures in the provision of care resulted in lost:
opportunities io treat her condition prior to her death”,
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| CIRCUMSTANCES OF THE DEATH
| failed to recognise that baby Jennifer was unweil until the time of her collapse, some
| thirty minutes after delivery. She was then transterred to the Luton & Dunstable hospital
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| Jennifer was born on the 24 September 2014 after a birthing pool delivery. The midwife |
| for further treatment where she died.
Senior Coroner, The Court House, Woburn Street. AMPTHEL 1. Bedfordshire. MiK4S AW
Fel 9308-300-6559 i Fax 0300-300-8267
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. —
H 1. a Consultant Paediatrician from the Hospital, during the course of his evidence,
explained that there were over 5,500 births at Watford General Hospital every
year, and that the Neonatal Unit only had a limited number of beds and was
inadequate for that number of births. Despite having submitted a detailed
Proposal for Expansion of the Neonatal Unit, this had been rejected
2. Without adequate neonatal facilities at the Hospital there is a high risk of babies’
lives being at risk in the future
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| ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you The
| Chief Executive of Watford General Hospital have the power to take such action.
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 10 March 2017. I, the coroner, may extend the period.
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| YOUR RESPONSE
|
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
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_ [have sent a copy of my report to the Chief Coroner and to the following Interested
: Persons:
: - Parents
Hertfordshire Safeguarding Children Board Team
I have also sent it to the Care Quality Commission and to
Paediatric Consultant of Watford General Hospital, who may find it useful or of
interest.
Tam also under a duty to send the Chief Coroner a copy of your Response.
Senior Coroner, The Court House, Woburn Street. AMPTHILL, Bedfordshire, MK45 2HX.
Tel 6300-300-6559 | Fax 0300-300-8267
| 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.
THOMAS R. OSBORNE
| Senior Coroner
Bedfordshire and Luton
Senior Coroner, The Court House. Woburn Street, AMPTHILL. Bedfordshire, MK45 2HX
Tei 9306-300-6559 {| Fax 0300-300-8267
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.
West Hertfordshire Hospitals NAS Trust Chief Executive’s Office Watford General Hospital Vicarage Road PRIVATE & CONFIDENTIAL The Senior Coroner The Court House Watford Woburn Street Herts Ampthill WD18 OHB Bedfordshire MK45 2HX 08 March 2017 Dear Sir, | am writing to you to respond to the concerns raised by Mr Thomas Osborne's investigation into the circumstances surrounding the tragic death of Jennifer Clark, which led to him making a regulation 28 report with respect to the issues discussed at the conclusion of the Inquest on 10 January 2017. Mr Osborne was concerned that without adequate neonatal facilities at Watford General Hospital there is a high risk of babies’ lives being at risk in the future. Based on the latest figures available, in 2015 5451 babies were delivered at Watford General Hospital. The Neonatal intensive Care Unit (NICU) is a designated Level 2 unit which provides neonatal care for the population within the West Hertfordshire catchment area, except for the sickest babies who require complex or longer-term intensive care in a Level 3 unit. We have a total of 24 cots (3 intensive care cots; 5 high dependency cots and 16 special care cots). Babies requiring Level 3 intensive care are transferred to the nearest Level 3 Intensive Care Unit within our regional neonatal network. Within the East of England Neonatal Operational Network there are eight units. Department of Health Toolkit for High Quality Neonatal Services’ suggest that planned capacity should not exceed an average occupancy of 80%. Our aggregate occupancy rate for all cots in 2015 was 69%. The Trust has, since 2015, a Neonatal Unit Admissions and Escalation Policy (enclosed), which sets out what actions are required when the Unit reaches 90% capacity. ate: /Nwww.londonneonatalnetwork.org. uk/wp-content/uploads/201 S/OS/Toolkit- 2009 pdf Shar: Pro or Steve Barnett Reflecting on the available data and Department of Health guidance set out within the Toolkit, the Trust considers that for the number of births there is adequate facilities available at Watford General Hospital. We do however recognise that the Neonatal Unit, along with many of our buildings, requires modernisation. On 2 February 2017 the Trust Board approved a redevelopment plan as part of the Your Care, Your Future Programme, which will include extensive redevelopment of hospital estates and facilities and this will include plans for development of the NICU. The Trust’s Strategic Outline Case is due to be considered at the Herts Valley Clinical Commissioning Group Board meeting; at the time of writing a date is yet to be set. | hope that the information provided offers assurances that the area highlighted in the prevention of future deaths report is being adequately managed and that there are wider plans that are going to improve services across the whole site for patients who require a variety of the services we are able to offer. We will continue to work with Level 3 Neonatal Intensive Care Units in ensuring the safety of babies born at Watford General Hospital who may require intensive care. Yours sincerely y ( CSch vrol Katie Fisher Chief Executive HM coc Inspection Manager HE (22d of Quality Assurance, Herts Valley CCG Mr Thomas Osborne, Senior Coroner, The Coroner's Office, 1 Saxon Gate East, Central Milton Keynes MK9 3EJ Encl. Escalation Process for Neonatal Intensive Care Unit
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