Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0297, written 26 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 | 26 Sep 2018 |
|---|---|
| Reference | 2018-0297 |
| Deceased | Bridget Marie Connell-Graham |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Child Death (from 2015) · Hospital Death (Clinical Procedures and medical management) related deaths |
| 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 |S BEING SENT TO: 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 5" February 2018 | commenced an investigation into the death of Bridget Marie Connell-Graham. The investigation concluded on the 20 August 2018 and the conclusion was one of Narrative: Died from the recognised consequences of premature birth the precise cause of which is unclear. The medical cause of death was Extreme prematurity On 1st February 2018 Bridget Marie Connell-Graham's mother went into premature labour at 20 weeks gestation at her home addressyggyy She was born at her parents address and subsequently transferred alive to Tameside General Hospital, on 1st February 2018 she died there from extreme prematurity. 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 inquest heard that at a scan performed on 31° January 2018 after an attendance the previous day with an episode of bleeding Bridget’s mother was found to have a shortened cervix. On 1° February she was bor prematurely. A history of cervical trauma was contained within the maternal notes. The inquest heard that whilst there is guidance from NICE as to the appropriate action to be taken where there is a history of cervical trauma there is no clear definition of what amounts to cervical trauma. The inquest was told that this means there is an inconsistent approach nationally as to what will be treated as a history of cervical trauma and therefore in what steps are taken in relation to investigating a previous history of cervical trauma and planning clinical treatment during pregnancy. 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 22" November 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 1] have sent a copy of my report to the Chief Coroner and to the following interested Persons ore of Bridget Connell-Graham, who may find it useful or of interest. | 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. Alison Mutch OBE HM Senior Coroner 26" September 2018 ATIVAN
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.
> From Jackie Doyle-Price MP’ Deparment Pastry Unt Seas Sis Mis Hea or riea Social Care 39 Vitoria Steet SWI1H OEU Your Ref: 9480/CLB 020 7210 4850 PFD-1150539 Ms Alison Patricia Mutch HM Coroner's Court 1 Mount Tabor Street Stockport SK1 3AG (November 2018 Deo, NA Martech, Thank you for your correspondence of 26 September to Matt Hancock about the death of baby Bridget Marie Connell-Graham. I am replying as Minister with portfolio responsibility for maternity care. I have noted carefully the matter of concern in your report. It is essential that we look to make improvements where we can to ensure the safety of healthcare services and prevent future deaths and I am grateful to you for bringing these matters to my attention. My officials have made enquiries with the National Institute for Health and Care Excellence (NICE). I am advised that the guideline, Preterm labour and birth (NG25)', includes a ‘Terms to use in the guideline’ section (at the end of Recommendations) that contains key definitions. This currently does not include a definition of cervical trauma. However, the full guideline document for NG25 does. The full guideline document contains the recommendations, the evidence they are based on and considerations of the guideline developers. It also contains a glossary which defines cervical trauma as “Physical injury to the cervix including surgery, for example, previous cone biopsy (cold knife or laser), large loop excision of the transformation zone (LLETZ) — any number) or radical diathermy”. ' https://www.nic .uk/euid 2: NICE has advised that it will ensure this definition is added to the ‘Terms used in this guideline’ section as soon as possible, so it is easily accessible to those looking over the recommendations. I hope this response is helpful. JACKIE DOYLE-PRICE
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