Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0015, written 26 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 | 26 Jan 2017 |
|---|---|
| Reference | 2017-0015 |
| Deceased | Albie Marlow |
| Coroner | Thomas Osborne |
| Coroner area | Bedfordshire and Luton |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Child Death (from 2015) |
| 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.
for Bedfordshire and Luton REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Ms Pauline Philip Chief Executive Luton & Dunstable Hospital Lewsey Road LUTON. LU4 0DZ | CORONER | am Thomas R. Osborne, Senior Coroner for Bedfordshire and Luton _2 ; CORONER'S LEGAL POWERS | | make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and i regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. : i http: /Awww.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 i i http://www jegislation.gov.uk/uksi/2013/1629/part/7/made |3 | INVESTIGATION and INQUEST 1 i i | | On 20 April 2016 | commenced an Investigation into the death of Albie Henderson Marlow. i . The Investigation concluded at the end of the Inquiry on 26 January 2017. The Conclusion of the | Inquiry was ‘Still Birth’ t | 4 CIRCUMSTANCES OF THE DEATH | i | Mother at 37 weeks gestation. She was taken for Category 2 Caesarean Section. There were _ Some difficulties in delivery of the baby due to adhesions and thick uterus: head pushed up to | enable difficult delivery. Fetal movement had last been perceived by mother on 8 April 2016 and | i fetal heart last heard 13 minutes prior to delivery. Baby Albie was born pale and floppy with no i | respiratory effort and no heart rate - Still Birth. Family state this was not the case and that Albie i | cried. 5 | CORONER’S CONCERNS During the course of the Inquiry 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. — , During the course of the Inquiry into the death of Baby Albie | heard that throughout labour his mother had asked for, and indeed, “begged” for a Caesarean Section delivery and her wish was not granted. She expressed concern that the delivery was following the same pattern as an Senior Coroner, The Court House, Woburn Street, AMPTHILL, Bedfordshire, Mk45 2HX Fel 0300-300-6559 | Fax 0300-300-8267 earlier pregnancy and it had resulted in a delivery by emergency C Section. It was apparent that if baby Albie had been delivered when mother requested a C section he would have survived. My concern is that mothers requesting delivery by Caesarean Section are not having their wishes respected and this is putting babies’ lives at risk. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you Chief Executive Luton & Dunstable Hospital 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 24 March 2017. |, 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. | [have sent.a copy of my r i roner and to the following Interested Persons: | | am aiso under a duty to send the Chief Coroner a copy of your response. COPIES and PUBLICATION Parents: and to the Care Quality Commission who may find it useful or of interest. The Chief Coroner may publish either or both in a compiete 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 youryesponse by the Chief Coroner. | THOMAS R OSBORNE Dated 26 January 2017 Senior Coroner Bedfordshire and Luton Senior Coroner, The Court House, Woburn Street, AMPTHILL, Bedfordshire, MK45 2HX Tel 0300-300-6559 | 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.
OE IC ERE eS SS LR UNIVERSITY HOSPITAL CLINICAL EXCELLENCE, QUALITY & SAFETY 23/03/17 Lewsey Road Luton LU4 0DZ Tet 01582 49 11 68 www.idh.nhs.uk Mr |. Pears HM Coroners Office The Court House Woburn Street Ampthill Bedfordshire MK45 2HX Dear Mr Pears, Luton and Dunstable University Hospital response to Regulation 28 Report in connection with the death of baby Albie Henderson Marlow Firstly, we would wish to offer our sincere condolences to Albie’s parents for the loss of their son and apologise for any experience that they felt was not as expected at the Luton and Dunstable University Hospital NHS Trust Maternity unit. We have reviewed the care as part of our investigations and the learning arising out of our investigations has been shared. Luton and Dunstable Hospital NHS Foundation Trust is committed to providing the highest quality care for all mothers and babies. The Regulation 28 Reports dated 31 January 2017 issued by HM Senior Coroner Tom Osborne states the following concern: “My concern is that mothers requesting delivery by Caesarean Section are not having their wishes respected and this is putting babies’ lives at risk” Unfortunately as not all of the respective clinicians directly involved in the delivery of care were called to attend the hearing and as live evidence on the discussion held with the respective disciplines of staff involved were not heard, we are confident the information contained in this response will reassure HM Senior Coroner respectfully that the Luton & Dunstable University Hospital NHS Trust does have policies and processes in place for mother’s requesting caesarean sections and our staff are skilled to understand and empower women of their right to choose for themselves whilst ensuring that the safety of mothers and infants remains paramount. We would respectfully submit that at the Luton and Dunstable Hospital NHS Trust we support and promote maternal choice of birth and work within our local and national guidelines. We have a local guideline (CG130); Management of pregnant women with previous lower segment Caesarean section or other uterine scar (‘Vaginal Birth After Caesarean section (VBAC)) and attach a copy for your consideration. We have a dedicated specialised VBAC clinic led by a Senior Consultant Obstetrician and a Consultant Midwife. The role of this clinic is to provide more detailed counselling and specialist support relating to options for women who have had a previous caesarean section. We can also confirm that we comply with the NICE guideline CG132 (copy attached) which elaborates on the care that is given to this cohort of women. Our specialist VBAC clinic is led by the Chairman: Simon Linnett + . + | uICL| Chief Executive: Pauline Philip Luton and Dunstable University Hospital NAS UCL Medical School Clinical Teaching Hospital Chair of this guideline. All women who attend this clinic are provided with the Royal College of Gynaecologist Guidelines (‘RCOG’) leaflet for VBAC (copy attached) and an individualised care plan is made for all such women which includes an elective repeat caesarean section (ERCS) if that happens to be the woman’s choice. Additionally, in line with NICE we have a Local Guideline for Maternal Requests for Caesarean Section (CG414) which we have also attached. It is important to clarify that there are two types of caesarean sections; planned and emergency. There is also a distinction between a woman being in labour or being induced. Whilst we do not wish to further rehearse the point, we wish to emphasise that as a care organisation we recognise the importance of individualised care; information is offered, women are listened to and their preferences are considered as well as respecting the choice of the birth. This is done in partnership with the midwife and doctor to achieve an outcome which is best for the mother and baby based on good clinical decision-making. We acknowledge that there are occasions when women in pain, in labour request caesarean sections. In such cases, a discussion with the consultant will determine the reason(s) for the request and work in partnership to achieve an outcome which is safe for mother and baby. The foliowing learning points were made as part of the Serious Incident investigation and we confirm that all actions relating to these have been completed and implemented. We have attached the Action Plan for your consideration. 1. In women undergoing IOL with a background history of previous caesarean section, it is good practice to undertake a full clinical assessment including abdominal palpation and a vaginal examination. This recommendation has already been incorporated into the revised VBAC (vaginal birth after caesarean) form. 2. The obstetric management team should consider how the timeliness of epidurals for pain relief can be improved. 3. The obstetric management team should review decision making around non-elective caesarean sections to ensure that classifications are appropriate. 4. Situational awareness: The need for staff to consider alternate delivery technique(s) earlier when faced with a challenging impacted fetal head at the time of delivery. It is hoped that the Trust response and attachments provided will assure HM Senior Coroner that the Trust does have policies and processes in place for mother’s requesting caesarean sections and our staff are skilled to understand and empower women of their right to choose for themselves whilst ensuring that the safety of mothers and infants remains paramount. Yours Sinter
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