Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0288, written 10 Sep 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 Sep 2018 |
|---|---|
| Reference | 2018-0288 |
| Deceased | Alba Pemberton |
| Coroner | Andrew Walker |
| Coroner area | London (North) |
| Category | Child Death (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Her Majesty’s Coroner for the Northern District of Greater London (Harrow, Brent, Barnet, Haringey and Enfield) North London Coroners Court, 29 Wood Street, Barnet EN5 4BE to H.M. Senior Coroner Clerk court.clerk@hmc-northlondon.co.uk REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Department of Health and Social Care, 39 Victoria Street, London, SW1H 0EU 1 CORONER I am Andrew Walker, senior coroner, for the coroner area of Northern District of Greater London 2 CORONER’S LEGAL POWERS I 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. 3 INVESTIGATION and INQUEST On the 12th March 2018 I opened an inquest touching the death of Alba May Pemberton , 2 days old. The inquest concluded on the 12th June 2018. The conclusion of the inquest was “Consequences of complications during the second stage in childbirth.”, the medical case of death was 1a Hypoxia, 1(b) Ischaemic Encephalopathy. 4 CIRCUMSTANCES OF THE DEATH On the Tenth of August 2016 Alba was born having suffered a period of hypoxia during the active stage of the second stage of the delivery. It is likely that by 21.45 hrs on the Ninth of August the active second stage had begun and that auscultation of the heart should have taken place every 5 minutes, this level of monitoring did not start until 23.12, This period had a bearing on Alba's death in that there is a possibility that 5 minute monitoring would have lead to the discovery of hypoxia at an earlier stage. If a CTG equipment had been used the trace is likely to have been abnormal for a considerable period and earlier delivery is likely to have resulted in Alba surviving. Alba was born seriously unwell as a consequence of the hypoxia and had only two days of life 5 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. – The presence of meconium should be classified as meconium, and not graded, and once present should result in the use of CCG equipment. That every patient at a birthing centre should be the subject of obstetric review Her Majesty’s Coroner for the Northern District of Greater London (Harrow, Brent, Barnet, Haringey and Enfield) That obstetricians should be more involved in the management of low risk cases There should be MDT meetings with the obstetric staff and midwifery staff and obstetric staff encouraged to work closely together in the management of low risk cases. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by the 5th November 2018 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons;- Representatives for the Trust and the Family. I 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 10-9-2018
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.
Ba From Jackie Doyle-Price MP’ Parliamentary Under Secretary of State for Mental Health, Department inequalities and Suicide Prevention of Health & Social Care EL eas SWiH OEU 020 7210 4850 PFD-1148325 Mr Andrew Walker HM Coroners Court 29 Wood Street Barnet EN5 4BE & November 2018 Deo Mr Weddle, I am writing further to the Regulation 28 Prevention of Future Deaths Report issued on 10 September following the inquest into the death of baby Alba May Pemberton. I am replying as Minister with portfolio responsibility for maternity care. My officials have made enquiries with the National Institute for Health and Care Excellence (NICE) and NHS Improvement on the matters of concern in your report. In 2014, NICE published clinical guideline (CG190), Intrapartum care for healthy women and babies', which sets out clear recommendations relating to risk assessment and place of birth. CG190 is evidence-based, using research results from a number of studies, including the Birthplace Study, 2011°, which provides robust data on the risks and benefits of each birth setting that healthcare professionals and women can use to make informed choices on the place of birth. CG190 does not recommend an obstetric review or that obstetricians should be more involved in low risk births. 1 https://www.nice.org.uk/guidance/ce 190 ? https://www. lac: Involving obstetricians in the midwifery-led care of women in a birth centre would undermine the woman’s choice for low-risk care and the midwife’s role as the lead for a normal birth. Rather than obstetricians being routinely involved in the care of women assessed as being at low-risk of complications, CG190 sets out clear recommendations relating to risk assessment and place of birth. There should be protocols in place locally regarding risk assessment, consultation with, and escalation to, obstetric care. It appears, from the information given, that the failings in this case related to a lack of ongoing clinical assessment and escalation once there were signs and symptoms of fetal distress. You indicate in your report that five-minute monitoring of the fetal heart rate was not followed by the healthcare professionals in the second stage of labour. As you will be aware, CG190, gives clear recommendations on the level of observations in the second stage of labour and the need to assess whether transfer of care may be needed: ‘Observations during the second stage: 1.13.2: Perform intermittent auscultation of the fetal heart rate immediately after a contraction for at least | minute, at least every 3 minutes’. With regard to meconium, CG190 defines the presence of meconium-stained liquor as either ‘non-significant’ or ‘significant’: e ‘Non-significant meconium is pale green or yellow amniotic fluid that is thin and with no lumps of meconium present. It is sometimes referred to as ‘light’ or ‘thin’ meconium. © Significant meconium is dark green or black amniotic fluid that is thick or tenacious or any meconium-stained amniotic fluid containing lumps of meconium. It is sometimes referred to as ‘heavy’ or ‘thick’ meconium’. The NICE guideline includes the following recommendations regarding documenting the presence or absence of significant meconium: ‘1.5.2 As part of ongoing assessment, document the presence or absence of significant meconium. This is defined as dark green or black amniotic fluid that is thick or tenacious, or any meconium-stained amniotic fluid containing lumps of meconium ”. « * ‘1.5.3 If significant meconium is present, ensure that: e healthcare professionals trained in fetal blood sampling are available during labour and e healthcare professionals trained in advanced neonatal life support are readily available for the birth”. ‘1.5.4 If significant meconium is present, transfer the woman to obstetric-led care provided that it is safe to do so and the birth is unlikely to occur before transfer is completed. Follow the general principles for transfer of care described in section 1.6”. NICE has advised that it considers that CG190 appropriately reflects the available evidence and does not need to be updated at this time. I am content to accept that position. You will wish to note that NICE will log the concerns in your report against this guideline topic so that they can be taken into consideration when NICE next comes to review the need for the guideline to be updated. Joule. JACKIE DOYLE-PRICE
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