Billy Wilson

Date of report	9 Mar 2017
Reference	2017-0061
Deceased	Billy Wilson
Coroner	David Hinchliff
Coroner area	West Yorkshire (East)
Category	Child Death (from 2015) · Hospital Death (Clinical Procedures and medical management) related deaths
Source	judiciary.uk record · original PDF
Responses published	1

The report

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.

ANNEX A

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)

NOTE: This form is to be used after an inquest.

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:

1. Jackie Smith, Chief Executive and Registrar, Nursing and Midwifery
Council, 23 Portland Place, Marylebone, London, W1B 1PZ

INVESTIGATION and INQUEST

CORONER

Lam David Hinchliff, Senior Coroner for the coroner area of West Yorkshire (Eastern)

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.

On 5" December 2013 | commenced an investigation into the death of f Billy Wilson,

3 days old. The investigation concluded at the end of the Inquest on 1 March 2017. The
conclusion of the Inquest was that the cause of death was 1(a) Hypoxic-ischaemic brain

injury 1(b) Perinatal asphyxia and a Narrative Conclusion was recorded, a copy of which
is attached hereto.

CIRCUMSTANCES OF THE DEATH

Billy Wilson was a baby boy born at 0250 hours on 27" November 2013 at Pinderfields
Hospital, Wakefield. He survived for 3 days and his death was confirmed on the
Paediatric Neonatal Unit at Leeds General Infirmary at 0140 hours on 30" November
2013. The cause of death is as stated above. This was a high risk pregnancy as it was
suspected that Billy's mother suffered with polyhydramnios and that Billy was thought to
be a large baby. The mother was admitted to Pinderfields Hospital on 21* November
2013 for inducement of labour. She was given a prostaglandin pessary which had little
effect. This was s repeated on the 22™ November 2013 and a third such pessary was
given on the 23" November 2013. Furthermore a prostin gel was used on 25'
November 2013, all of which were without gain. The mother’s uterine contractions and
the baby’s heart rate were monitored with a cardiotocograph (CTG). On one occasion
the intermittent CTG tracing showed contractions to be 6 or 7 in 10 minutes —
hyperstimulation. Notwithstanding this the mother was started on an oxytocin drip, the
dose of which was steadily increased, which obviously increased and strengthened the
frequency of the contractions. In Billy's case the monitoring of the CTG on 26"
November 2013 showed an abnormality, which should have caused the syntocinon to
be stopped. From 1740 hours onwards an expert review identified significant failings in
care by both Midwives and Obstetricians, notwithstanding repeated irregularities in both
the frequency of contractions and the foetal heart rate, yet the syntocinon was continued
and on occasions was increased. Billy suffered from excessive stress and periods of
hypoxia caused by the hyperstimulation and the fact that the labour was not
progressing. The syntocinon should have been stopped. At 2000 hours the care of the

mother was allocated to a newly qualified Midwife. This was only her first night shift and

YOUR RESPONSE

only her sixth shift since qualifying in September 2013. This Midwife was not able to al
interpret the CTG printout as being pathological and she increased the syntocinon.
When it was finally realised that the baby was in distress and likely to be brain damaged
he was delivered by forceps, in a poor state. He was resuscitated and then transferred
to the Neonatal Paediatric Intensive Care Unit at Leeds General Infirmary where, despite
all efforts, he deteriorated and his death was confirmed at 0140 hours on 30" November
2013. The newly qualified Midwife referred to in her evidence stated that she had not
received appropriate instruction or training during her Midwifery Course at Bradford
University and that when she became registered and took up her first appointment she
had not completed the second part of an E-learning programme on the interpretation of
CTG traces. An expert witness on Midwifery issues stated that this is commonplace and
that student Midwives can qualify and become registered without this essential training.

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) | request that you ensure that training on CTG tracing interpretation is contained in
the Undergraduate Syllabus for all Midwifery Degree Courses throughout the country.
(2) That this is compulsory and that it has to be assessed on a pass or fail basis, and
that a student Midwife cannot seek registration until this vital etement in training is
undertaken.

(3) That Hospital Trusts should not recruit newly qualified Midwives until they can
demonstrate their understanding and proficiency in CTG tracing interpretation.

(4) There should be formal refresher training for all practising Midwives in CTG tracing
and interpretation done on a yearly basis, and that this should be assessed on a pass or
fail basis, and not merely left to the responsibility of the individual Midwife to complete
an E-learning package without Management Review and assessment.

ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe you and your

organisation 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 Thursday 4° May 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.

COPIES and PUBLICATION

| have sent a copy of my report to the Chief Coroner and to the following interested
Persons — President of The Royal College of Obstetricians and Gynaecologists and

Ameritus Professor in Obstetrics and Gynaecology. | 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 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.

9 March 2017

Senior cbr ner, West Yorkshife (Eastern

Responses

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.

Response from Royal College of Obstetricians and Gynaecologists (PDF)

Royal College of
Obstetricians &
Gynaecologists

Direct telephone: +44 (0)207 772 6238
Email: president@rcog.org.uk

Mr David Hinchcliff

Senior Coroner, West Yorkshire (Eastern)
Coroner's Office and Court

71 Northgate

Wakefield WF1 3BS

3 May 2017

Dear Mr Hinchcliff
Your ref: DH/ST/893/15 re Baby Karpovich / DH/KLA/3156/13 re Billy Wilson

Thank you for writing to me on 22 February and 8 March 2017 regarding the inquest of the deaths of
Maxim Karpovich and Billy Wilson. | responded re on 17 March 2017 after meeting
and discussing with the RCOG Officers and seeking input and advice from the new Vice Presidents of
Education and Clinical Quality. | apologised tT for the delay in my response
explaining that ! heeded to consult with the Curriculum Review team in some detail before | could
address his concerns appropriately. The consensus frem the RCOG Officers and the Curriculum
Review team was that a theoretical course in itself — particularly a course taking place over many
weeks as was being suggested — was unrealistic for all trainees, many of whom are struggling to
obtain study leave from their Trusts and are also complaining bitterly about the mandatory training
modules that they are expected to complete. There is also the question of whether a course is the
most appropriate method of training as the problems that can arise in clinical practice are generally
when the whole picture is not considered and the issue is not escalated appropriately.

Cardiotocograph (CTG) training is part of the current RCOG curriculum. In summary it is part of
module 10 ‘Management of labour’ and by the end of Specialist Training year 1 (ST1), all trainees
must produce evidence of having completed a course demonstrating CTG interpretation skills (see
Module 10 attached with relevant sections highlighted) before they can progress to become an ST2.
As you will see this is usually an e-learning course and the resources which most trainees use are
either the K2MS™ PTP (Perinatal Training Program) package or the e-learning for Healthcare
Electronic Fetal Monitoring chapter. You may be aware that the K2 training requires hospitals to
have a site licence and trainees can then be registered. The e-learning for Healthcare requires
doctors to have a NHS email address and then they can register for free, but this precludes those
working out with the NHS. However | should mention here that, as the official host, the RCOG has
put a significant amount of resource into supporting the eFM package, working with the Royal
College of Midwives and Health Education England.

Royal College of Obstetricians and Gynaecologists 27 Sussex Place, Regent's Park, London NW! 4RG
Telephone: +44 (0)20 7772 6200 Facsimile: +44 (0)20 7723 0575 Website: www.rcog.org.uk

Registered chanty no. 213280

Royal College of
Obstetricians &
Gynaecologists

CTG training is additionally included in the basic practical skills course which all trainees have to take
to progress to ST3. One of the 10 practical stations is on interpretation of CTG and fetal blood
sampling. All delegates are expected to complete the on-line tutorials in electronic fetal monitoring
and fetal blood sampling during the pre-course preparation and should have a basic understanding
the fetal monitoring principles.

In terms of the new curriculum, the pressure of completing modules does not allow us to increase
the emphasis on CTG interpretation but it will remain an important that trainees evidence this skill.
The RCOG opinion on CTG interpretation is that the problems arise in clinical practice when the
whole picture is not considered, and this is why trainees are encouraged to demonstrate clinical
competence within teams as part of workplace based assessments. In addition senior trainees who
are likely to be in charge of such teams can register for our Advanced Training Skills Module (ATSM)
in advanced antenatal practice or advanced labour ward practice, both of which contain curricula
that deliver additional training in the teamwork around CTG interpretation which includes the
running of team meetings and reviews of decision making . mee details a our ATSM programme
can be found at https:

Whilst we fully understand the concerns around this case we would like to reassure you that the
College is committed to ensure that safety is at the heart of anything we do. We have discussed
whether one additional course such as that proposed by Professor Steer for all our trainees would
enhance safety. We believe that it would not and that we should therefore concentrate on ensuring
consistency of our curriculum and also fully engaging with NHS England and the ‘Safer Maternity
Care’ programme, launched by Jeremy Hunt at the RCOG in October 2016. This important national
programme has come with a very strong bias towards team work and leadership, supported by a
new funding stream for multi-professional training programmes.

As | am sure you are aware, the Secretary of State announced £8m of funding for maternity safety
training last Autumn 2016, with at least £40k to each NHS Trust in England. This has allowed some
units to fund training in subjects such as team working in intrapartum care and CTG interpretation
via courses that have already been established.

Lastly | should mention that in my reply Ri reminded him that the RCOG currently
offer an “intrapartum fetal surveillance course” which is run over one day at the RCOG and is aimed
at obstetric team working. | suggested to hat he could liaise with our Convenor of
Meetings to help us design a pilot programme along the lines that Professor Steer proposes, that

Royai College of
Obstetricians &
Gynaecologists

could then be trialled at the RCOG. | offered to give this my full support if he wished to pursue the
proposal and | believe that he has already started to do so.

If you would like to discuss this further with me please do not hesitate to contact me.

Yours sincerely

(tobe

President

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The report

Responses

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