Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0154, written 21 May 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 May 2018 |
|---|---|
| Reference | 2018-0154 |
| Deceased | Carter Jepson |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Other 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Secretary of State for Health CORONER lam 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 6" November 2017 | commenced an investigation into the death of Carter Isaac Jepson. The investigation concluded on the 18" May 2018 and the conclusion was one of; Natural Causes The medical cause of death was; la Unascertained l4 Carter Isaac Jepson was a healthy, well cared for child. On 3rd November 2017 he was put to bed in his Moses basket by his mother. He showed no signs of ill health. At about 04.00 on 4th November 2017, his mother found him not | breathing in his Moses basket. An ambulance was called and arrived promptly. Carter was taken to Stepping Hill Hospital where resuscitation attempts continued. He died at Stepping Hill Hospital at 05.40 on 4th November 2017. There were no suspicious circumstances. Post mortem examination confirmed that his death was due to natural causes, although the precise cause of his sudden death could not be ascertained. + 5 | CORONER'S CONCERNS During the course of the inquest, the evidence revealed matters giving rise to H 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 inquest heard that Carter had been breastfed. Following his death, his mother was significantly impacted, psychologically, by his loss. The inquest heard that this was exacerbated because there was no process/protocol in place to prescribe her medication to stop lactation. As a result she continued to lactate whilst dealing with her loss. The inquest heard that the SUDC paediatricians dealing with the case had identified this as a national issue relating to breastfeeding mothers dealing with the trauma of the unexpected loss of their child. i 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 16" July 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. /8 | COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons ani mother 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 21/05/2018
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.
fesPomse
4,
MP From Jackie Doyle-Price MP
Parliamentary Under Secretary of State for Mental Health and Inequalities
Department Department of Health and Social Care
of Health 39 Victoria Street
London
SW1H 0EU
Your reference: 8622/CH
Our reference: PFD 1133566 RECEIVED
13 JUL 2018
CH
Ms Alison Mutch OBE sae Sast a.
HM Senior Coroner, Manchester South
Coroner’s Court
1 Mount Tabor Street A
Stockport
SK1 3AG [{ suty 2018
Neo. Aw Mate.
Thank you for your letter of 21 May to the Secretary of State for Health and Social
Care about the death of Carter Isaac Jepson. I am responding as Minister with
portfolio responsibility for women’s health and maternity care.
Your Report raises a matter of concern that, while not involving a risk of future
death, can clearly be a very distressing physical experience after the death of a baby,
and it is concerning to hear that you heard evidence at inquest that a lack of support
might be a national issue.
My officials have sought advice on what guidance is available on the suppression of
lactation following the loss of a baby, and the role of medication.
I am advised by the Medicines and Healthcare products Regulatory Authority
(MHRA) that at present Bromocriptine and Cabergoline are licensed for the
suppression of lactation for medical reasons and particular indications (such as when
breast feeding is contraindicated due to medical reasons related to the mother or the
new-born).
Bromocriptine is not recommended for the routine suppression of lactation or the
relief of symptoms or post-partum pain and engorgement which can be adequately
treated with non-pharmacological intervention (such as firm breast support, ice
application) and/or simple analgesics.
The NHS Specialist Pharmacy Service provides the following information, updated in
April 2016, on these medications:
These dopaminergic drugs are used for the treatment of specific pituitary and
prolactin-mediated disorders, including galactorrhoea, hyperprolactinaemia and
prolactinomas, They are also used to suppress lactation by inhibiting prolactin
secretion although symptoms of post-partum pain and engorgement can normally be
adequately treated with simple analgesics and breast support.
Although cabergoline is the only drug licensed for routine suppression of lactation,
its use is not usually recommended. Bromocriptine and quinagolide are off-label
(unlicensed) for routine lactation suppression.
Bromocriptine is not recommended as several cases of maternal seizures, stroke,
psychiatric effects (including psychosis) and death have been reported when used for
suppression of lactation. This is supported by a 2014 EMA recommendation.
Cabergoline has not been associated with serious maternal adverse effects. Small,
incremental doses may reduce, but not completely suppress lactation, although this
cannot be guaranteed.
Safety in Lactation: Bromocriptine and other dopaminergic drugs, published 20th
May 2012, updated 19th April 2016!
The evidence therefore suggests that the medications may not fully suppress lactation
and can be associated with significant side effects.
Of key importance is that women should be given information about their choices for
lactation suppression and be informed of the relative advantages and disadvantages of
each approach.
Non-pharmacological methods for lactation suppression are available to women and
are covered in guidance, such as that published by the stillbirth and neonatal deaths
' https://vww.sps.nhs.uk/articles safety-in-lactation-bromocriptine-and-other-dopaminergic-drugs
a
Department
of Health
charity, SANDS. Pregnancy Loss and the Death of a Baby’, wpdated in 2016, is
widely endorsed and recognised as setting out best practice in bereavement care.
The guidance acknowledges that choices around lactation are deeply personal, and
makes clear the importance of the provision of information and support to enable
bereaved parents to make the choices that they feel are right for them.
Discomfort can be associated with non-pharmacological methods such as ice packs,
analgesics and support bras. However, there are measures that can be taken to reduce
that discomfort such as warm showers; using cloths cooled with cold water; and/or
gradual decrease in frequency of expression of milk. Some women may choose to
donate their milk to a breast milk bank. The United Kingdom Association for Milk
Banking provides support to healthcare professionals and bereaved mothers across
the UK who are looking for information about donating milk’.
It is therefore for NHS trusts to ensure they have in place comprehensive,
compassionate guidance for bereavement care which includes the provision of
information and support on lactation suppression, based on best practice and
evidence.
To support the NHS further in this regard, you will be interested to learn that the
National Institute for Health and Care Excellence (NICE), is currently in the process
of updating its guideline on postnatal care up to 8 weeks after birth’, and, after being
made aware of the concerns in your Report, has decided to add the issue of
suppression of lactation to the scope of the guideline.
NICE expects to publish the final updated guidance in August 2020, though this date
may be subject to change. I hope this information is helpful.
Finally, the death of a child is a tragedy in any circumstance. You will be aware that
all child deaths in England are required by law to be reviewed to learn lessons and to
help prevent future deaths.
We will shortly be publishing new statutory guidance on the process for child death
reviews in England to ensure a uniform, high-standard of reviews locally and that
each local area is able to capture learning that may be applicable at the national level.
pregnancy-loss-and-0
3 http://www.ukamb.org/
* https://www.nice.org.uk/guidance/cg37
Each death is to be scrutinised by those involved in the care of the child, and from a
broader independent and anonymised perspective at a Child Death Overview Panel.
In addition to new statutory guidance, a national child mortality database has been
commissioned by NHS England and is expected to become fully operational by
Spring 2020. Through the database, the findings from reviews will be shared
nationally and will enable learning aimed at saving children’s lives. The database will
support thematic learning and help the Department and its system partners to
understand the causes of child mortality better and enable changes both locally, and
nationally.
The database is set to be the most extensive internationally, in that it is the first to
cover the deaths of all children, from those who show a sign of life following birth
through to their 18" birthday. Additionally, the database will be aligned with the
perinatal mortality review tool”, in order to collect data from the reviews of the
circumstances and care leading up to and surrounding each stillbirth and neonatal
death.
| hope the information I have provided is helpful. Thank you for bringing your
concerns to our attention.
JACKIE DOYLE-PRICE
* https://wwww.npeu.ox.ac.uk/pmrt
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