Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0005, written 9 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 | 9 Jan 2017 |
|---|---|
| Reference | 2017-0005 |
| Deceased | Ana Sirghi-Marin |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: Prevention of Future Deaths report
Ana Geanina SIRGHI-MARIN (died 29.07.16)
THIS REPORT IS BEING SENT TO:
1.
2.
Vice President, Clinical Quality
Royal College of Obstetricians and Gynaecologists
27 Sussex Place
Regent’s Park
London NW1 4RG
President
British Maternal and Fetal Medicine Society
27 Sussex Place
Regent’s Park
London NW1 4RG
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 2 August 2016, I commenced an investigation into the death of Ana
Geanina Sirghi-Marin, who died on 29 July 2016 aged 36 years. The
investigation concluded at the end of the inquest on 5 January 2017. I
made a determination at inquest as follows.
1
Ana Sirghi-Marin died because of a naturally occurring uterine infection,
when she was sixteen weeks pregnant. She had become pregnant by in
vitro
fertilisation (IVF) and had undergone an amniocentesis at
approximately 1pm on 27 July 2016.
I recorded a medical cause of death of:
1a Escherichia coli sepsis
1b choriamnionitis
1c second trimester pregnancy.
4
CIRCUMSTANCES OF THE DEATH
It appears that the amniotic E coli pre-dated the amniocentesis, as it was
later determined to be present in the amniotic fluid drawn off that day.
It is unclear whether conception by IVF played any part in the infective
process.
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.
The amniotic fluid drawn off at amniocentesis two days before death was
neither purulent nor blood stained, but was discoloured dark yellow.
Given the rarity of such non blood stained discolouration, I heard
evidence that it would be a wise precaution in this situation always to
send a sample for immediate microbiological analysis, and quickly to
follow up the result.
I say always because, at the time of the amniocentesis, there was no
fever or other indicator of infection, yet when Ms Sirghi-Marin presented
at the emergency unit the following afternoon she was very unwell, and
she died the next morning.
Such action would not have changed the outcome in this instance,
because presentation to the emergency unit took place approximately 26
hours after the amniocentesis. However, it might in another case. And
given the rarity of such non blood stained discoloured amniotic fluid, a
guideline that this action is necessary does not seem onerous.
2
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that you have the power to take such action.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date
of this report, namely by 13 March 2017. 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.
8
COPIES and PUBLICATION
I have sent a copy of my report to the following.
HHJ Mark Lucraft QC, the Chief Coroner of England & Wales
Care Quality Commission for England
, Chief Medical Officer for England
Director, Homerton University Hospital
, husband of Ana Sirghi-Marin
I 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
interest. You may make
representations to me, the Senior Coroner, at the time of your response,
about the release or the publication of your response by the Chief
Coroner.
it useful or of
find
9
DATE SIGNED BY SENIOR CORONER
09.01.16
3
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.
Coroner M E Hassell Senior Coroner Inner North London St Pancras Coroner’s Court Camley Street LONDON N1C 4PP 7 March 2017 Dear Coroner Hassell, Re: Prevention of Future Deaths following Amniocentesis Thank you for your letter dated 9 January 2016. In this you describe the death of a lady, Ana Geanina Sirghi-Marin, 2 days after an amniocentesis, during which the liquor was noted to be discoloured dark yellow but no action taken in response to this unusual appearance. The liquor was not purulent nor blood stained. You have recorded a medical cause of death of: 1a E-coli sepsis 1b Chorioamnionitis 1c Second Trimester Pregnancy Subsequently, E-coli was grown from the amniotic fluid, indicating that the infection predated the amniocentesis. You have suggested a wise precaution in future cases – namely to send samples of non-blood stained discoloured amniotic fluid off for culture and quickly to follow-up the result. Although this may not have prevented the death in this case, in other cases it may do so. We note that you have not suggested that antibiotics might also have been administered in this case. Having read your summary, we think that this should also have been a consideration. Again, whilst it may not have prevented the maternal death, it might do so in future cases. Current guidelines on amniocentesis were published in 20101 and are due for a renewal. The risk of severe sepsis, including maternal death, is described with a risk < 1/1000 procedures quoted. Whilst emphasis is given to reducing skin contaminants or organisms present on the ultrasound probe and gel by decontamination of probes between patients, and following standard practice to avoid inadvertent puncture of the bowel, no discussion is made on the issue of the finding of discoloured or, for that matter, purulent fluid at amniocentesis. Similarly, the guideline does not mention whether prophylactic antibiotics are justified in all, or in special circumstances and if not, why not. We have discussed your recommendations with the joint chair of the Royal College of Obstetricians & Gynaecologists’ Guidelines Committee. They have informed us that the Coroner’s recommendations will be taken into consideration when the next revision of the Green-top guideline is issued, but in order to bring this matter to the attention of specialists performing amniocentesis more quickly, we would recommend that the Royal College of Obstetricians and Gynaecologists consider adding a prominent notice on their website (in particular on the page featuring the guideline for amniocentesis) encouraging doctors to consider sending amniotic fluid for bacteriological examination as the Coroner has suggested, with consideration of antibiotic treatment if there is evidence of intra-amniotic infection. We suggest the wording of this notice should read: “If, on inspection of the amniotic fluid following amniocentesis, it has a cloudy or purulent appearance or the patient shows clinical features to suggest intra-amniotic infection, the operator should consider sending a small quantity of amniotic fluid for microbiological analysis and consider antibiotic treatment”. We hope that the above action is a satisfactory and appropriate response to the findings of your inquest. Yours sincerely On behalf of the British Maternal & Fetal Medicine Society RERERENCES 1. RCOG. Amniocentesis and Chorionic Villus Sampling. 2010; Green-top Guideline No 8.
See every Prevention of Future Deaths report matching Hospital Death (Clinical Procedures and medical management) related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.