Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0253, written 21 Aug 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 Aug 2018 |
|---|---|
| Reference | 2018-0253 |
| Deceased | Kiarah Allen |
| Coroner | Louise Hunt |
| Coroner area | Birmingham and Solihull |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. CRG Lead Commissioner 2. Birmingham Women’s and Children’s NHS Foundation Trust CORONER tam Louise Hunt Senior Coroner for Birmingham and Solihull 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 25/04/2018 | commenced an investigation into the death of Kiarah Faith Adora Allen. The investigation concluded at the end of an inquest on 20th August 2018. The conclusion of the inquest was: Kiarah died from an inadvertent fluid overload of TPN given via an UVC as a result of unsafe staffing levels, not correctly following procedure and failing to learn from a previous similar event. Her death was contributed to by neglect. CIRCUMSTANCES OF THE DEATH Kiarah was born at 25 plus 5 weeks gestation on 09/02/18 at 20.00. She was admitted to the neonatal unit where she required medical support including Total Parenteral Nutrition (TPN) with starter vamin. On 10/02/18 at around 11.20 her TPN needed changing to Neo 12. At the time two junior sisters were involved. During the course of the change one junior sister was called away to another baby. During the change both types of TPN were inadvertently left attached to the baby via the umbilical venous catheter (UVC). The start-up Vamin continued to go through the pump however the Neo 12 was attached directly to the UVC. When the clamp to the UVC was removed the Neo 12 infused direct into Kiarah leading to fluid overload of 209mls. This caused her to collapse about an hour later requiring resuscitation. The fluid overload led to severe metabolic complications. She sadly died at 00.55 on 11/02/18. The root cause of this error was a combination of unsafe staffing numbers, a failure to follow correct procedure when changing the TPN and failure to learn from a previous similar incident. Following a post mortem, the medical cause of death was determined to be: dla CONGESTIVE CARDIAC FAILURE ib ACCIDENTAL TOTAL PARENTERAL NUTRITION FLUID OVERLOAD dc VERY PRETERM (25/40), CONGENITAL BILATERAL BRONCHOPNUEMONIA, HYPOXIC-ISCHAEMIC BRAIN INJURY AND INTRAVENTRICULAR HAEMORRHAGE 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. — 4. | heard evidence in the inquest that at the time this incident occurred there were unsafe levels of nursing and clinical staff. The funding provided for nurses assumed the unit was only 85% full. Therefore when the unit was full, there was insufficient numbers of nurses and doctors. Consideration needs to be given to providing additional funding to enable the unit to be appropriately staffed for the very sick babies they care for. 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" October 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:- Kiarah’s family lam 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. 21/08/2018 Signature basthiud Louise Hunt Senior Coroner Birmingham and Solihull Districts
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.
eiaan: INHS RECEIVED. pet Birmingham Women's 15 OCT 2018 and Children’s NHS Foundation Trust Dr Fiona Reynolds Chief Medical Officer Executive Team Birmingham Women’s and Children’s NHSFT Steelhouse Lane Birmingham B4 6NH www.bwe.nhs.uk Mrs Louise Hunt HM Senior Coroner Birmingham and Solihull 50 Newton Street Birmingham B4 6NE 12 October 2018 Dear Mrs Hunt Kiarah Faith Adora Allen — Regulation 28 Report to Prevent Future Deaths | write further to the inquest touching the death of Kiarah Faith Adora Allen which you held on 20 August 2018 and your subsequent Report to Prevent Future Deaths, dated 21 August 2018. Firstly, | would like to reiterate the Trust's sincere and profound condolences to Kiarah’s family. Further to the evidence presented to you on 20 August, you concluded that Kiarah died from an inadvertent fluid overload of Parenteral Nutrition (PN) given via an umbilical venous catheter (UVC) as a result of unsafe staffing levels, not correctly following procedure and failing to learn from a previous incident. Her death was contributed to by neglect. Your Report dated 21 August 2018 highlighted concerns in regards to funding for the unit and specifically highlights that the unit is funded for 85% occupancy. | have had sight of the response from NHS England in regards to the neonatal commissioning arrangements and can confirm that we are continuing to work with our colleagues at NHS England to better understand and improve the commissioning and funding arrangements to support our neonatal service. By your side Chairman Professor Sir Bruce Keogh Chief Executive Officer Sarah-Jane Marsh Alongside these discussions we continue to invest a significant amount of time and effort into improving our Neonatal Intensive Care Unit (NICU) at Birmingham Women’s Hospital to enhance the service afforded to our patients and their families, and to prevent a recurrence of the circumstances which led to the devastating incident and Kiarah’s tragic death. eee | would like to take this opportunity to update you on progress against the action plan which was developed in response to our root cause analysis (RCA) investigation into this incident and submitted to you prior. to the inquest (also attached to this response for ease of reference). : You will be aware from the RCA and action plan submitted to you prior to the inquest that many. changes have been recommended and these changes are being implemented as part of an on-going work plan. Referring to the action plan, the following actions have been completed and new practices dictated within those actions are being embedded: «Action 1;A new nursing competency for safe. administration of PN has been developed and all staff have been retrained and assessed against the competency before being allowed to continue administering PN. 9. All eligible staff have been re-educated and assessed against the up to date trust wide PN.’ competency. All new members of staff will attend the study day as part of the new. NICU _ Foundation programme. This has been. in place since July 2018 ¢ ‘Action 2; Nurses are allocated to specific babies each shift. o. The nurse in. charge (NIC) is allocating babies to nurse every. shift. This is being reinforced though the staff weekly newsletter. «Action 3; Each shift a specific nurse should be allocated to hold the bleep. and their name is. documented. on the NIC paperwork. : o. The bleep is allocated to a ‘specific nurse, and there is also a back up nurse. every shift. This is embedded within daily practice. Action 4; The Nurse in charge handover is to: be shortened to.ensure that the Situation report (SITREP) is completed and babies are moved, if required. ae °.. Anew sit rep form:has been finalised and is in use. *.. Action 5;.A new workforce plan will be developed by the senior leadership in neonates. : 0. The workforce plan is live, but recovery through increased recruitment is on-going. «Action 6: A shift planner to be incorporated on the back to the new handover checklist. 0. The shift planner.and handover checklist is launched and in use. * Action 8; The use of the trolley when completing PN to be embedded into the competency for PN. 9. Trolley use is embedded, with a guide and labels attached, *. Action 10; Include the disposal of the old: PN in the training competency for: PN. : 9. The competency document-has been approved and is in use. . «Action 11; A-checklist is to be created when PN is being changed, this allows the person to check in and check out of the task. ; ; : Bas 9. The competency document has been approved and is in use ® Action 14: An Education Plan will be produced to include the care of the sick neonate and embed learning. A student liaison role has also been created to support delivery of training. 6. The education plan began in October.2018 . e Action 20; There should be a member of staff with the parents during witness resuscitation o. Witnessed resuscitation is part of our. standard. practice and is being reinforced: in simulation training : : e Action 24: Head of Nursing to complete and implement a NICU workforce plan. o. The Workforce plan is being implemented and the NICU e-roster has been. reconstructed and aligned to the workforce plan. With regards to the remaining actions, | would like to update you as to the progress of this change. as. follows; i : * Action 7; Observation charts with a RAG rated ward round jobs list are to be created. and implemented, - . o. This. project is on-going; the NICU team are working. with the medical. illustration department to devise a draft chart for piloting. : e. Action 9; Previous shift NIC to. review babies and move them.where necessary. : : o. Within current practice, the NIC is moving babies where ever. possible to permit the safest possible care, however this is not yet fully embedded e Action. 12; The doors of the clinical rooms are to be left open, during key tasks, when infection control allows. : : o. Culture change is on-going “e Action 13; Head of Nursing to price the vocera system for staff to be able to summon support from colleagues, if required. : ; 0. Pricing for Vocera for all clinical areas is a current on-going task e. Action 15; The Women’s site requires site management service cover. . o. In planning * Action 16; Band 7 (special care) or discharge liaison lead to work weekends to ensure leadership is more visible on the NICU. : : o. The Neonatal Head of Nursing or Matron are sending daily sit rep. to Managers for. neonatal RAG status. Currently, this occurs.on week days only. : e. Action:17; Standardise practice for.lumen use when completing PN. changes. o..Not yet achieved ; : ¢ - Action 18; Label_all the lines near to the Baby. : : -"-9. Additional labels were. ordered in September. This is embedded jin in. nursing practice, where we have appropriate labels i e Action.19; Always havea leader: during resuscitation who is not task focussed and therefore is able to have situational awareness. “9 The resuscitation equipment is being checked daily and regularly being reviewed by the Leadership and Resuscitation team. Advanced Resuscitation of Newborn Infant (ARNI). ' ens course and team training is focussing on resuscitation team leadership and: human factors to ensure the team leader does not get involved in tasks but maintains a leadership role for better situational awareness Action 21; Head of Nursing to. price the ARNI training for. NICU. nurses to replace Newborn Life Support (NLS) course : : oe : o.. ARNI was not to replace NLS, but to complement it as both are required. This will form part of the suite of resuscitation courses available across the trust. ARNI implementation is on hold whilst the Resuscitation Team at the Trust is recruited to. ¢ Action 22; Human factors training: 0. The annual staff training day has been redesigned and Human factors will be included in this training which began in September. It will take a year to deliver this to all staff. * Action 23; Blood gas checking to be incorporated into the simulation training. 9. Two nurses have attended training to become able to run simulation training. A plan is - being put in.place to devise the training Package together with a Neonatal Consultant. [hope that this serves to reassure you that the Trust has taken this incident, and Kiarah’s subsequent tragic death, very seriously and that we are working hard within the ‘current financial: constraints to. improve our service. Dr Fiona Reynolds Chief Medical Officer : ; Birmingham Women’s and Children’s NHS Foundation Trust
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