Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0043, written 11 Feb 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Feb 2019 |
|---|---|
| Reference | 2019-0043 |
| Deceased | Calary Davis |
| Coroner | David Regan |
| Coroner area | South Wales Central |
| Category | Child Death (from 2015) · Hospital Death (Clinical Procedures and medical management) related deaths · Wales prevention of future deaths reports (2019 onwards) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
ANNEX A
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
NOTE: This form is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
The Chief Executive of the Cwm Taf University Health Board
1 CORONER
I am David Regan, Assistant Coroner, for the coroner area of South Wales
Central
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
A Coronial investigation was commenced on 16th January 2018 into the death
of Calary Fern Davis. The Investigation concluded at the end of the inquest
which I conducted on 6th – 8th February 2019. The conclusion was a narrative
conclusion and the medical cause of death was 1a. Hypoxic Ischaemic
encephalopathy
4 CIRCUMSTANCES OF THE DEATH
These were recorded as :-
Calary Davis was delivered by emergency Caesarean Section on 31st December
2017. She had suffered a period of acute fetal bradycardia which caused hypoxic
ischaemic encephalopathy resulting in very serious damage to her brain. Her
, had been admitted for induction on 28th December 2017,
mother,
but that induction had not proceeded normally down the induction clinical
pathway.
had received no planned obstetric review during the course
of her admission, and no obstetrician had discussed her care with her. The Cwm
Taf University Health Board accept that there were a number of shortcomings
proceeded to Artificial rupture of membranes in
in her care. Had
1
accordance with the appropriate clinical pathway, it is likely that Calary would
not have suffered hypoxic ischaemic encephalopathy and would have survived.
The narrative conclusion which I returned was:
Calary Davis died as a result of hypoxic ischaemic encephalopathy which arose
from fetal distress and bradycardia to which she was subject within the hour
prior to emergency caesarean section. It is likely that she would have survived
if, during her admission for induction, her mother had proceeded to Artificial
rupture of membranes in good time in accordance with the appropriate clinical
pathway.
The Inquest focused upon:-
a. The fact that
had received no planned obstetric review
during her admission 28 – 31 December 2017 and had no clear care
plan
b. She spent an unacceptably lengthy period of time awaiting artificial
rupture of membranes (ARM)
c. There were opportunities for
to have been progressed down
the induction pathway, which were missed.
d. Calary Davis was an otherwise healthy baby who would have survived
had her mother been treated in accordance with the induction pathway
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. –
(1) The action plan annexed to the root cause analysis remained
incomplete. It is understood that this arises in part from the merger of
the maternity services of the Royal Glamorgan and the Prince Charles
Hospitals.
(2) It was accepted at Inquest that the merger of the maternity units of the
two hospitals, while potentially creating a future single centre of
expertise, does risk causing a period of institutional stress to maternity
services which have exhibited some significant shortcomings.
(3) There is a review of 43 such cases which was said to be considering
them individually rather than analysing common themes and trends.
(4) In
’ case, proceeding to ARM would have been possible but
there was a culture in the unit not to perform it at night
(5) There was a reluctance from mid ranking midwife staff to challenge
decisions made by the labour ward coordinators
2
(6) Decisions by those coordinators were made without full information as
to the clinical needs of the patients awaiting transfer to the labour ward
(7) There was a poor standard of safety briefing, provision of information
on patient handover and multi-disciplinary team assessment
(8) There were insufficient staffing levels, despite which the escalation
policy was not used.
(9) There was a lack of band 7 midwife and obstetric team leadership.
6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe
you and 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 10th April 2019. 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 family who may find it useful or of interest.
Health inspectorate Wales, Welsh Government, Medical Director of Cwm Taf
University Health Board.
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
11th February 2019 SIGNED:
D Regan
Assistant Coroner
(Electronic Signature)
3
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.
\ GIG c(pol ~~ NHS rr Bwrdd lechyd Prifysgol Cwm Taf University Health Board Your Ref/eich cyf: Our Ref/ein cyf: Date/dyddiad: Tel/ff6n: Fax/FFacs: Email/ebost: Dept/adran: 18/2636/1NQ 5" March 2019 01443 744800 01443 744889 Patient Care & Safety Unit Private & Confidential Mr David Regan Assistant Coroner Pontypridd Coroners Court Court House Street Pontypridd CF37 lJW Dear Mr Regan RE: Regulation 28 - Calary Fern Davis Thank you for the correspondence in relation to the above Regulation 28 received on 11 February 2019, which details the areas of concern following the conclusion of the inquest held between 6- 8th February 2019. Please be assured that the Health Board has taken this matter extremely seriously. Lessons have been learnt, following investigation and further informed by the findings of the inquest. The detail provided below align with the numerical order in which you presented your concerns and aims to capture actions taken to minimise the risk of any recurrence: Actions implemented: The action plan annexed to the root cause analysis remained incomplete. It is understood that this arises in part from the merger of the Maternity Services of the Royal Glamorgan and the Prince Charles Hospitals. A corrective Action Plan for Improvement was developed following Calary Davis' death. This has been updated to reflect the concerns identified within the Regulation 28 Report. The individual action plan has a completion date of August 2019, however, work is ongoing for the overarching maternity services action plan. All plans will be monitored through the Impovement Board and the Quality Safety Board. 1. It was accepted at the Inquest that the merger of the maternity units of the two hospitals, while potentially creating a future single centre of expertise, it does risk causing a period of institutional stress to maternity services which have exhibited some significant shortcomings. Return Address: Cwm Taf University Health Board, Headquarters, Navigation Park, Abercynon, CF45 4SN Chair/ Cadeirydd; Professor Marcus Longley Chief Executive/ Prif Weithredydd: Mrs A Williams Cwm Taf University Health Board is the operational name of the Cwm Taf University Health Board/Bwrdd lechyd Prifysgol Cwm Taf yw enw gweithredol Bwrdd lechyd Prifysgol Cwm Taf An overarching action plan was developed which identified the ongoing needs for the merger of the two sites. This plan is monitored weekly within the directorate and monthly from the Executive Director of Nursing, Midwifery and Patient Services. Work has been ongoing for the last five years in preparation for the Paediatric, Neonatal and Obstetric change to services. This is monitored monthly through the Service Change Board as part of the South Wales Programme. 2. There is a review of 43 such cases which was said to be considering them individually rather than analysing common themes and trends. The 43 cases have been reviewed, common themes and trends idenitified and these have been incorporated into the overarching action plan for maternity services. A review of all neonatal and stillbirths from January 2016 was undertaken to offer assurance that all cases had been through the governance process and enabled learning. The review has been undertaken with a multidisciplinary approach and monitored weekly through the Maternity Assurance Group. The review of these cases has been overseen by the Welsh Government Delivery Unit. The Delivery Unit has undertaken assurances of the methodology applied to ensure a system learning from the incidents. 3. In Mrs Davis' case proceeding to Artifical Rupture of Membranes would have been possible but there was a culture in the unit not to perform this at night. All delays for planned activity are now monitored and datix reported. The Health Board is introducing a live acuity tool which allows for delays to be captured. The Senior Midwife is responsible for ensuring that all delays are escalated. This is then reviewed during the weekly incident reporting meeting. The Organisational Development Plan is centred around addressing custom and practice leading to ineffective cultures. The plan has already been implemented and work will continue with all disciplines through the year. 4. There was a reluctance from mid ranking midwife staff to challenge decisions made by the labour ward coordinators. The Health Board has developed an Organisational Development Plan addressing human factors and to work with all staff grades to develop a positive culture of challenge and openess. The Health Board also implemented a new Escalation Policy with work specifically focussed on midwives being able to jump call to the Obstetric Consultant and Senior Midwife on call. The Clinical Supervisor for Midwives is undertaking escalation work within group settings. s. Decisions by those coordinators were made without full information as to the clinical needs of the patients awaiting transfer to the Labour Ward. A new electronic whiteboard is being implemented. This will have red flags to identify and review women in a timely manner. The whiteboard allows for accurate data capture of all inpatients and the date and time of admission. This is a proven quality improvement programme which ensures a multidisciplinary approach in patient safety. Consultants are calling the Labour Ward out of hours and discussing each case with both the Middle Grade and the Band 7 Midwife Co-ordinator to ensure plans are in place and support is given. This is occurring at 10pm every night in addition to the daily ward rounds undertaken by the Obstetric Team. Return Address: Cwm Taf University Health Board, Headquarters, Navigation Park, Abercynon, CF45 4SN Chair/ Cadeirydd; Professor Marcus Longley Chief Executive/ Prif Weithredydd: Mrs A Williams Cwm Taf University Health Board is the operational name of the Cwm Taf University Health Board/Bwrdd lechyd Prifysgol Cwm Taf yw enw gweithredol Bwrdd lechyd Prifysgol Cwm Taf 6. There was a poor standard of safety briefing, provision of information on patient handover and multi-disciplinary team assessment. A quality improvement programme to ensure handover and safety briefings are delivered to a high standard, has been incorporated into our maternity action plan. The action plan is monitored weekly through our Assurance meetings and audits are undertaken from the Senior Midwifery Team. All safety briefings are retained for audit purposes. These are working well and have a multidisciplinary focus, which is improving communication and team working. 7. There were insufficient staffing levels, despite which, the escalation policy was not used. Staffing has significantly improved since August 2018. We have a rolling advert for recrutiment of midwives and this is monitored closely. The merger of the two units assists with the difficulties of the shortfall. Currently the Health Board has a vacancy of 15 WTE Midwives with midwifery staffing now at 90% of the required midwifery levels for the service. Staffing is monitored weekly through our Assurance Board and a Senior Midwife on call rota is in place and was implemented in July 2018. Please refer also to point 5. 8. There was a lack of Band 7 Midwife and Obstetric Team leadership. The Organisational Development Action Plan and two planned leadership study days in June and July 2019 are being undertaken to improve clinical leadership and team working within the department. The Organisational Development Plan will focus on multidisciplinary team working and clinical leadership. Our mandatory training includes communication, documentation and escalation as part of the yearly updates. I sincerely hope that this information and enclosed action plan will reassure you that the Health Board has learned important lessons from the investigation into the care provided to Calary Davis and that effective action has now been taken to prevent further deaths. I would like to convey, once again, my deepest sympathy and sincere apologies to the family of Calary Davis for the failings identified. Yours sincerely la Helo, %.66 -rec a 7kca-vs· or &C2.U¢ ·5' Mrs Allison Williams Chief Executive Officer Return Address: Cwm Taf University Health Board, Headquarters, Navigation Park, Abercynon, CF45 45N Chair/ Cadeirydd; Professor Marcus Longley Chief Executive/ Prif Weithredydd: Mrs A Williams Cwm Taf University Health Board is the operational name of the Cwm Taf University Health Board/Bwrdd lechyd Prifysgol Cwm Taf yw enw gweithredol Bwrdd lechyd Prifysgol Cwm Taf
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