Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0062, written 1 Mar 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 Mar 2018 |
|---|---|
| Reference | 2018-0062 |
| Deceased | George French-Russell |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Community health care and emergency services related deaths · Child Death (from 2015) |
| Organisation named | Stockport NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
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REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT tS BEING SENT TO: Chief Executive of Stepping Hill Hospital, Chief Executive of East Midlands Ambulance Service, Chief Investigating Officer of Healthcare Safety Investigation Branch and the Secretary of State for Health CORONER | am Alison Mutch, Senior Coroner, for the coroner area of South Manchester 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 1* February 2017 | commenced an investigation into the death of George French Russell. The investigation concluded on the8th February 2018 and the conclusion was one of: Narrative: Died from the recognised complications of a breech birth contributed to by the absence of expert input during delivery The medical cause of death was la Hypoxic ischaemic encephalopathy b Preterm prolonged footling breech birth CIRCUMSTANCES OF THE DEATH On 11th January 2017 as 35 weeks plus 1 pregnant with George Edward French-Russell. At about 11:30am she rang triage at Stepping Hill Hospital and was advised by an unqualified maternity assistant to take paracetamol, rest and ring back in an hour if required. At about 12:30pm she rang the High Peak Community Midwife Team and the call taker agreed a midwife would call her back. At about 1:00pm she spoke with a midwife and described her symptoms. A face-to-face appointment was arranged for 2:20pm that day. At 1:20pm, she rang 999 and spoke to East Midlands Ambulance Service control (EOC). A crew was dispatched as a red Lat 1:21:56pm. The target response time was 8 minutes. The call handler remained on the line with who told her that her waters had broken; she was 35 weeks pregnant and wanted to push. At 1:28:18pm, EOC updated the crew that her waters had broken. No contact was made with the midwifery team at Stepping Hill Hospital for advice. The position remained that the crew were to assess. The crew asked if a midwife was on the way. At 1:38:28pm, the ambulance arrived on scene. wanted to push. At 2:42pm, EOC rang Stepping Hill Hospital triage. Triage was not given all the information known by East Midlands Ambulance Service. They asked if she wanted to push. It was confirmed she did. East Midlands Ambulance Service was advised to transfer as an emergency to Stepping Hill Hospital. The transfer time was 30 minutes plus and the crew at 1:44pm did not believe there was time to transfer. At about 1:55pm the crew rang Stepping Hill Hospital triage direct after being given the number by EOC. Stepping Hill Hospital triage was told that George was a footling breech. The paramedic had not dealt with a breech birth before. A doctor spoke to the ambulance crew who wanted advice. The call between the crew and the doctor terminated before George was born. No further expert advice was sought by the crew to inform how they managed George's delivery. The doctor did not do anything further. George had not delivered when the second crew arrived at 2:06pm. The second crew assisted with George's delivery. He was born at 2:15pmina poor condition. Midwives arrived on the scene shortly after his birth. An airway was established and he was transferred to an ambulance and then to Stepping Hill Hospital. After assessment, he was transferred to Bolton Hospital for neonatal care. His prognosis was poor due to the severe brain damage at birth. On 23rd January 2017, he died at Royal Bolton Hospital after he was extubated. 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. During the inquest it became clear that during the telephone conversation between EMAS and George’s mother her labour was rapidly developing. There was no evidence of the call taker seeking guidance on how to deal with a rapidly evolving situation other than to update the ambulance crew who were on route.(EMAS) 2. The way in which information was exchanged between Stepping Hill Hospital and EMAS meant that all those involved in making decisions were not in possession of key facts. There was no structure to how information was shared and it was passed 3 hand. 3. During labour EMAS were present. The paramedics did not have the experience to deal with a footling breech delivery. Expert input was given for a brief period by a registrar but when that conversation tw terminated there was no further support given or sought. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you 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 26" April 2018. |, 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 namely ii” father of the deceased who may find it useful or of interest. 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. Alison Mutch OBE HM Senior Coroner / /: WSS
3 responses 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.
RG From Jackie Doyle Price MP’ Department Parliamentary Under Secretary of State for Mental Health and inequalities of Health 39 Victoria St London SW1H OEU 020 7210 4850 Ms Alison Mutch OBE HM Senior Coroner Manchester South Coroner’s Court 1 Mount Tabor Street Stockport SK1 3AG Our reference: PFD 1122493 25 April 2018 Veo ha, Martek, Thank you for your letter of 1 March to the Secretary of State for Health and Social Care about the death of George Edward French-Russell. I am responding as Minister with responsibility for maternity care. Your report raises several areas of concern which are operational and for the NHS Trusts involved to address. Learning lessons where things have gone wrong is essential to ensuring the NHS provides safe, high quality care. My officials have made enquiries and I am assured the East Midlands Ambulance Service NHS Trust and the Stockport NHS Foundation Trust are taking steps to make improvements in response to this tragic death. I understand the Trusts are responding to you with details of the action taken and I will not repeat that information here. However, I am encouraged that both organisations are working together to share learning from this incident. You may wish to be aware that the National Institute for Health and Clinical Excellence (NICE) published a guideline on Preterm labour and birth! in November 2015. The guideline covers the care of women at increased risk of, u https://www.nice.org.uk/guidance/ng25 or with, symptoms and signs of preterm labour (before 37 weeks) and women having a planned preterm birth. This guidance recommends that women presenting with symptoms of preterm labour should be offered a clinical assessment (NG25, 1.7.2 Diagnosing preterm labour for women with intact membranes), which regrettably, does not appear to have been offered in this case. You may be interested to know that NICE is currently developing a guideline on Intrapartum care for high risk women, which is expected to be published in March 2019. The guideline will be considering the optimal mode of birth (emergency caesarean section or continuation of labour) for women with breeching presenting in the first or second stage of labour. The death of a baby is a devastating tragedy and we must do all we can to make the NHS the safest place in the world to give birth. In November 2017, we launched Safer Maternity Care: progress and next steps’, which set out progress against the delivery of the national maternity ambition to halve the rates of stillbirths, neonatal and maternal deaths and brain injuries that occur during or soon after birth by 2025. To make sure progress is made quickly, we also set out an expectation of a 20 percent reduction by 2020. Safer Maternity Care sets out a number of steps to make sure we are doing all we can to prevent serious incidents in maternity services. This includes developing the role of the Healthcare Safety Investigation Branch’ (HSIB) to standardise investigations of cases of severe brain injury, intrapartum stillbirths, early neonatal deaths and maternal deaths in England so that the NHS learns as quickly as possible from what went wrong and shares this learning as widely as possible to prevent future tragedies. As well as providing comprehensive final reports for each case it investigates, the HSIB will publish themed reports drawing together overarching themes and points of learning from multiple investigations and making appropriate recommendations for system bodies to act on these findings. 2www.gov.uk/government/uploads/system/uploads/attachment_data/file/662969/Safer_mater nity care _-_progress_and_next_steps.pdf 2 https://www.hsib.org.uk/ Department of Health The new investigative approach will begin in a single region from April 2018 and will continue to roll out to all areas of England by April 2019. When fully rolled out, the HSIB will investigate around 1,000 cases a year with the expectation that the learning from investigations will spur system improvements leading to fewer deaths and injuries in the future. I am aware that the HSIB has responded to you to advise that, as this incident occurred before its establishment on | April 2017, it does not meet the criteria for investigation. Nevertheless, the information provided will assist the HSIB develop a wider picture of safety issues in the NHS and help inform future investigations. I hope this offers assurance that we are committed to learning from deaths and taking action to prevent future tragedies in maternity care. Thank you for bringing the circumstances of George’s death to our attention. JACKIE DOYLE-PRICE
East Midlands Ambulance Service NHS Trust Trust Headquarters 1 Horizon Place Mellors Way Nottingham Business Park Nottingham NG8 6PY Telephone: 0115 884 5000 Fax: 0115 884 5001 Website: www.emas.nhs.uk CONFIDENTIAL Our Ref RH/PFD 26 March 2018 Mrs A Mutch OBE HM Senior Coroner Coroner’s Court 1 Mount Tobor Street Stockport SK1 3AG Dear Mrs Mutch Re: Report to Prevent Future Deaths: Master George Edward FRENCH-RUSSELL (deceased) Thank you for your Regulation 28 Report to Prevent Future Deaths, dated 1*' March 2018 (received on 2" March 2018), bringing to my attention HM Coroner’s concerns arising from the Inquest into the death of Master George Edward FRENCH-RUSSELL. | would like to assure you that within the East Midlands Ambulance Service (EMAS) all matters related to patient safety are taken extremely seriously. In particular, matters arising from Coroners’ Inquests from which lessons can be learnt, including Prevention of Future Death Reports, are discussed within the Incident Review Group and Lessons Learned Group. This process has been applied to the Prevention of Future Deaths notice pertaining to the Inquest into the death of Master George Edward FRENCH-RUSSELL. The MATTERS OF CONCERN specific to EMAS are as follows: . During the inquest it became clear that during the telephone conversation between EMAS and George’s mother her labour was rapidly developing. There was no evidence of the call taker seeking guidance on how to deal with a rapidly evolving situation other than to update the ambulance crew who were on en route (EMAS) . The way in which information was exchanged between Stepping Hill Hospital and EMAS meant that all those involved in making decisions were not in possession of key facts. There was no structure to how information was shared and it was passed 3" hand East Midlands Ambulance Service NHS Trust 3. During labour EMAS were present. The paramedics did not have the experience to deal with a footling breech. Expert input given for a brief period by a registrar but when the that conversation was terminated there was no further support given or sought | set out below the actions that EMAS proposes to take and our response to HM Coroner's concerns as detailed in the PFD notice. Point One: The EMAS emergency operations centre (EOC) has in place a structured triage and escalation system to ensure that patient safety is embedded across the call handling and dispatch systems. Our advanced priority medical dispatch system (AMPDS) is designed to enable an objective clinical prioritisation of all callers; within this system is the ability to amend clinical details in the event of a change in condition. This is included within the system design, training programmes and audit processes. The result of any new information could create an amended prioritisation (escalation of priority only). In the event of a clinical need for telephone guidance such as first aid or aiding the delivery of a child, AMPDS has step by step guidance for telephone support that is appropriate for the clinical scenario. This advice is routinely provided across a range of conditions and is audited on a regular basis to ensure compliance. In the event of a deterioration or clinical concern identified by the non-clinical emergency medical dispatcher (EMD) the EMAS dispatch protocols have in place two systems of support and safety netting. A “help card” system enables a team leader to support a call process and escalate to a clinically trained member of the team. If it is identified that the priority allocated by the system is incorrect, for example, in cases such as a potential sepsis or antepartum haemorrhage there is a process of escalation via the EMD team leader to a clinician based within the EOC. This is recorded in the electronic records and a paper slip is produced as a part of this handover process in each case. Our Dispatch Officers are then enabled to update our clinicians en route to patients, of any significant changes. The application of any update is time related and is contained within a dynamic risk assessment framework to ensure that the passing of information is only performed when it is required and does not cause delay the ambulance crews. To ensure a more timely and objective Trust approach to community obstetric support EMAS has developed a standardised minimum criteria for requesting support from a remote service and from an on scene clinician. This is expected to be implemented in May 2018 subjected to governance processes. As an interim measure, guidance has been issued by clinical bulletin and to all relevant EOC staff. Point Two: EMAS recognises the importance of good communication and information sharing in relation to the delivery of high quality care and patient safety. As such EMAS will now implement a communication framework to ensure the provision of good quality clinical handovers, the SBAR model. The SBAR model (standing for: Situation, Background, Assessment, Recommendation) is a structured communication tool that is considered a best practice element in healthcare settings and has been East Midlands Ambulance Service NHS Trust in use within EMAS for a number of years as a generic method for communication. To enhance this, EMAS have enhanced the tool to include maternity specific guidance. This structured approach will provide an outline for standardising the quality of clinical communications in a maternity specific scenario. With regards to the specific concerns identified by HM Coroner's inquest we are also working with our obstetric service partners to extend the SBAR to create a maternity specific model. This approach has been formally shared with our network partners through the East Midlands Maternity Clinical Advisory Group following a debate in early March 2018, in draft format for agreement as a standardised regional handover tool. This is planned for implementation across the EMAS footprint in May 2018 subject to governance approval. In order to address the issue for units outside of the East Midlands region, we have arranged to meet with the various providers to explore working partnerships and inform them of our revised handover and communication processes. Point three: As a part of the engagement with our maternity receiving units, EMAS is working to promote the use of recorded facilities to complement EMAS'’ recording ability. Each receiving unit has been requested to ensure that the relevant clinical advice line is recorded to enable analysis of call data to facilitate any necessary learning. Additionally EMAS is exploring the expansion of our recording ability to include remote clinician carried devices. This has been incorporated into a wider IT infrastructure plan as it has significant financial and technical implications. In order to ensure that our clinicians are supported in making safe and effective clinical decisions we have provided all clinical staff with clinical guideline books and have commissioned an electronic app version to launch in April 2018. Further support is enabled remotely through our Clinical Assessment Team, which includes Nurses, Paramedics and Midwives. With specific regard to the call contact being prematurely ceased, all clinical staff have been reminded of the importance of escalating advice call failings to ensure appropriate advice and support is obtained . EMAS acknowledges its responsibility to enact a duty of care to all patients. Please do not hesitate to contact me should you require any additional information, or any clarification, in connection with the above. Yours sincerely Richard Henderson Chief Executive
Friday, March 16, 2018 Alison Mutch OBE HM Coroner’s Office, Manchester South The Coroner’s Court, 1 Mount Tabor, Stockport, SK1 3AG Dear Ms. Mutch, Thank you for contacting the HSIB regarding the case of the death of George Edward French-Russell. As you may be aware, the HSIB was set up to investigate systemic safety issues that cut across organisational boundaries. We conduct up to 30 investigations a year and focus on those with the most potential for new learning that have taken place after we became operational on 1st April, 2017. This case occurred before 1st April 2017 and therefore does not meet our criteria for investigation. The concerns raised highlight a demonstrable need for improvement in this area, and the information provided will help the HSIB build a wider picture of safety issues in the NHS. This in turn will enable us to more accurately determine which investigations should be prioritised in the years ahead. Thank you again for contacting us and we are sorry that we are not able to take this forward. However, if it is of interest, I would be very happy to meet with you and further explain how the HSIB may assist with future Coronial investigations Yours sincerely, Keith Conradi Chief Investigator, HSIB
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