Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0300, written 14 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 | 14 Aug 2018 |
|---|---|
| Reference | 2018-0300 |
| Deceased | Enric Elliott |
| Coroner | Fiona Wilcox |
| Coroner area | London Inner (West) |
| Category | Child Death (from 2015) · Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Whittington Health NHS Trust |
| 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: Ms Siobhan Harrington, Chief Executive, Whittington Health NHS Trust Magdala Avenue London N19 SNF CORONER | am Dr Fiona J Wilcox, HM Senior Coroner, for the Coroner Area of Inner West London 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 the 18" July 2018, evidence was heard touching the death of Enric Albert Alejandro Elliott. Enric had died on the 24k November 2017 in St Mary's Hospital after being found collapsed and then resuscitated at his home address on the 20'" November 2018. He was just 5 months old at the time of his death. The findings of the court were as follows: Medical Cause of Death 1 (a) Diffuse hypoxic- ischaemic brain injury (aka hypoxic-ischaemic encephalopathy) (b) Sudden unexpected death in infancy How, when and where the deceased came by his death: On 20/11/2017, Enric was found not breathing by his mother at his home address. LAS was called and he was resuscitated at the scene. Return of spontaneous circulation was achieved and he was transferred to hospital. Despite all treatment he died on 24/11/2017 at St Mary’s Hospital of brain injury due to the cardiac arrest. The cause of the initial arrest is unknown. He was well cared for and there were no suspicious circumstances. Conclusion of the Coroner as to the death: Natural Causes Circumstances of the Death. Evidence taken at the inquest from Head of Safeguarding at Whittington Health was that Enric’s mother had not been referred to Family Nurse Partnership because she had booked one week too late at 29 weeks gestation, referrals only being accepted until 28 weeks gestation, despite Enric’s mother’s young age and psychosocial vulnerabilities. If such a referral had been made it is likely that Enric’s mother would have agreed and accepted the extensive support provided by the Family Nurse partnership. It could not be said that such support would have changed the outcome in this case and in fact Enric’s mother was caring well for her child, despite her difficult circumstances. Since Enric’s death the rules around gestation and referral have become more flexible and some mothers who book after 28 weeks may be referred. Concerns of the Coroner: 1. That young women who book later than 28 weeks can only be considered for referral to the Family Nurse Partnership, despite the fact that late booking is often a further risk factor indicating increased vulnerability to the mother and young child. That late bookers may still be debarred from referral on the basis of gestation. That such vulnerable mothers are thus excluded from the support offered by the Family Nurse Partnership and thus their child be at increased risk of death in infancy. 4. That the increased risk to mothers and babies of late booking does not appear to be recognised as a positive reason supporting referral to the Family Nurse partnership. en ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you [AND/OR your organisation] have the power to take such action. It is for each addressee to respond to matters relevant to them. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report. 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons : 1. Head of Safeguarding, Whittington Health NHS Trust. Head of legal Services, st. | 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. 14th August 2018 Dr Fiona J Wilcox HM Senior Coroner Inner West London Westminster Coroner’s Court 65, Horseferry Road London. SW1P 2ED
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.
27 September 2018 . Dr Fiona J Wilcox HM Senior Coroner Whittington ‘Health NHS Trust Executive Offices Magdala Avenue London N19 5NF Web: www.whittington.nhs.uk Inner West London Westminster Coroner’s Court 65 Horseferry Road London SW1P 2ED Dear Dr Wilcox Ref: PFD 14-8-18 Whittington Health NHS Trust response to Regulation 28 Report La Prevent Future Deaths dated 14 August 2018. Thank you for raising your concerns regarding the referral criteria for vulnerable young people into the Family Nurse Partnership (FNP) programme. We recognise the importance of the issues you have raised and we are grateful to you for bringing your concerns to our attention. As required under our duty to respond to your report dated 14 Auiguse a 2018, we hereby detail actions taken and those proposed to. be taken in reporise to the concems you have raised. in your report. These being: . That young women who book later than 28 weeks [gestation] can [not] only be considered for referral to the Family Nurse Partnership, despite the fact that late booking is. often a further risk factor indicating increased vulnerability to the mother and young child. That late bookers may still be debarred from referral:on the basis of gestation. : That such vulnerable. mothers are thus. éxcluded ‘from the support offered by the Fainily Nurse Partnership and thus their child be at increased risk of death in infancy. That the increased risk to mothers and babies of late booking does not appear to be recognised as a positive reason-supporting referral to the Family Nurse Partnership. The FNP programme is an evidence-based intensive home visiting programme delivered through a national license for practice to which local providers of the programme are required to adhere. The programme, which is voluntary for clients to join, includes.a number of-Core Model Elements that prescribe how the programme should be-delivered to ensure continuous high clinical quality. The programme is based on over 30 years of rigorous evaluation and is built upon the theoretical.basis of attachment, self-efficacy and. human ecology. The FNP programme aims to support young mothers to have a healthy pregnancy; improve their child’s health and development; and plan their own futures and achieve their aspirations. UCLPartners __ Helping local people V7 i See Seppo Paare iy live longer healthier Chair: Steve Hitchins Chief Executive: Siobhan Harrington Following your PFD, our Trust FNP lead has met with both our local commissioners and the national FNP Team to agree how we can further implement local flexability to the delivery of the FNP programme. In agreement with the national team, we have made a change to our referral criteria so that mothers up to the age of 25 years old are now accepted into the local programme. As a result of your PFD, we have agreed that we can consider with the London FNP team, on a case by case basis, accepting referrals for mothers who are willinging to engage with the FNP programme when they are referred after 28 weeks gestation, particularly when there are .a further range of needs, vulnerabilities and issues associated with concealed pregancy. The national team have clarified with us that one of the Core Model Elements of the FNP programme is that clients should be recruited to the programme before the 28" week of pregnancy. This is because the therapeutic relationship takes some time to form, and is the basis for the important work the nurse and client undertake together; including the importance of attachment, early-infant development and the promotion of good health and wellbeing during the antenatal period, alongside usual antenatal services. The FNP programme sets a further goal that. 60% of all clients should be recruited by the 16" week in pregnancy, giving such an important window of opportunity for the nurse and client to work towards the important outcomes within the programme aims as set out above. When a mother is not able or willing to join the FNP programme, the Trust’s Health Visiting service will undertake a full assessment of need based on the Healthly Child Programme, and will ensure that our enhanced Health Visiting programmes — Universal Plus and Universal Partnership Plus — are activiey offered to families with additional needs and vulnerabilities. These enhanced service offers, whilst not part of the FNP programme, do provide an opportunity to work collaborativley with young and vulnerable mothers and their children delivering similar evidenced based interventions to those offered through the FNP programme. _ The national FNP team have informed:-us that the issues raised by your PFD are pertinent because they have taken the opportunity for evidence-based adaptation and testing to explore offering FNP to mothers later in gestation in certain circumstances, and to test the impact of this. The national FNP team are undertaking a range of research-based programmes that they call ADAPT (Accelerated Design and Programme Testing) to test some local personalisation of the programme. As part of the ADAPT work programme, the team are testing relaxing the existing 28 week gestation threshold for women, particularly with concealed pregnacies. This testing will take some time to ensure rigorous evaluation and they anticipate to report on this and other elements of the ADAPT project next year. ; : We,'as a local provider of the FNP programme, will continue to work with the national FNP team to test the impact on programme outcomes for any referrals that happen over 28 weeks gestation, and we will work with the national team to add to the considerable evidenced base of the national FNP programme. —. ; ; . Yours sincerely Siobhan MOU TOUR Chief Executive
See every Prevention of Future Deaths report matching Whittington Health NHS Trust, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.