Prevention of Future Deaths reports · 2019

Jenson Francis

Regulation 28 report to prevent future deaths, reference 2019-0158, written 17 May 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report17 May 2019
Reference2019-0158
DeceasedJenson Francis
CoronerDavid Regan
Coroner areaSouth Wales Central
CategoryChild Death (from 2015) · Hospital Death (Clinical Procedures and medical management) related deaths · Wales prevention of future deaths reports (2019 onwards)
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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.

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
CORONER

I am David Regan, Assistant Coroner, for the coroner area of South Wales
Central

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.

INVESTIGATION and INQUEST

A Coronial investigation was commenced on 2™ July 2018 into the death of
Jenson James Francis. The Investigation concluded at the end of the inquest
which I conducted on 16" — 18" May 2019. The conclusion was a narrative
conclusion and the medical cause of death was 1 (a) cardio pulmonary failure;
1(b) maternal sepsis, chorioamnionitis, and funisitis; 1(c) prolonged rupture of
membranes

CIRCUMSTANCES OF THE DEATH

These were recorded as :-

Jenson James Francis was delivered by caesarean section on 21% June 2019. He
developed chorioamnionitis and funisitis as a result of maternal sepsis. While
the presence of maternal sepsis affecting his mother, a been
identified, there were failures on the part of the clinical care to identify that the
CTG was abnormal or pathological from about 22.16 on 20" June 2018 or to

arrange for urgent delivery by caesarean section. Thereafter, there was an
absence of review by an obstetric doctor from 01.45 — 04.00 on 215' June 2018,

when the sole available doctor was detained in theatre, and an absence of a jump
call. Had proceeded to caesarean section it is likely that Jenson.
James Francis would have been less exposed to maternal sepsis and survived.

The narrative conclusion which I returned was:

Jenson James Francis died of Cardio pulmonary failure as a result of a failure to
deliver him in good time, exposing him to the effects of developing maternal
sepsis

The Inquest focused upon:-

a. The failure of the obstetric and midwife staff properly to classify the CTG
trace as abnormal, including deficiencies in their training

b. A lack of medical cover on the labour ward while the only available

doctor was detained in theatre

Unclear leadership structure within the clinical team.

Systemic failures within the maternity unit, with fragmented consultant

cover, inadequate support for trainee and middle grade doctors, high

usage of locum staff and the lack of awareness of guidelines, protocols,

triggers and escalations.

9. 9

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 root cause analysis characterises the presence of a “dysfunctional
team without a clear leader.” Evidence at the Inquest and in the report of
the Royal College of Obstetricians and Gynaecologists dated 16" April
2019 identified a culture of unclear clinical leadership and a perceived
inability on the part of more junior staff to challenge or review decisions.

(2) There was a poor standard of CTG interpretation, with insufficient
training and review

(3) There was unclear communication as to whether a category | or 2
caesarean section was required.

(4) NEWS charts and partograms were not completed, and there was a poor
standard of record keeping.

(5) There were insufficient staffing levels, and very high acuity, despite
which there was no consultant attendance and the escalation policy was
not used. There was evidence that there was no clear line of responsibility
for identifying this and ameliorating it.

(6) The recent merger of the maternity units of the Prince Charles and the

Royal Glamorgan 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.

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.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this
report, namely by 18" July 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.

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.

17'* May 2019 SIGNED: D Regan
(Electronic Signature)

Responses

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.

Response from University Health Board (PDF)
Your Ref/eich cyf: 
Our Ref/ein cyf: 
Date/dyddiad: 
Tel/ff©n: 
Fax/FFacs: 
Email/ebost: 
Dept/ad ran: 

DR/JJF/Reg28 
18/2759/1 NO 
10 July 2019 
01443 744800 
01443 744889 

Patient Care & Safety 

8, '? \-eee 
?<'J/' ][[g  m Taf Morgannwg 
' University Health Board 
·J" wits 

Private & Confidential 
Mr David Regan 
Her Majesty's Coroner 
Pontypridd Coroners Court 
Court House Street 
Pontypridd 
CF37 lJW 

Dear Mr Regan 

Re: Regulation 28 - Jenson James Francis 

Thank you for the correspondence in relation to the above Regulation 28 received by the 
Health Board on 17 May  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 details  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 

1  The root cause analysis characterises the presence of a "dysfunctional team 
without a clear leader".  Evidence at the inquest and in the report of the 
Royal College of Obstetricians and Gynaecologists dated 16° April 2019 
identified a culture of unclear leadership and a perceived inability on the 
part of more junior staff to challenge or review decisions. 

There is an Organisational  Development Action Plan to focus on many areas of the 
multiprofessional  teams in  maternity services.  Within the plan there  is support for 
multidiscipliary team working and clinical leadership. Included in the plan are two study 
days in July and October 2019 supported by the Royal College of Midwives to improve 
clinical  leadership  and  team  working  within  the  department.  The  mandatory 
professional  training  days  include sessions on  communication,  record  keeping  and 
documentation and esclation. This plan  focuses on individual team members as well 
as groups. PROMPT is now fully implemented into the Health Board with all staff booked 
for training before the end of March 2020. Training compliance is monitored through 
the HB Maternity Improvement Board. 

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 

 
 2.  There was a poor standard of CTG interpretation, with insufficient training 

and review 

The  Health  Board  has  implemented  the  All  Wales  Intrapartum  Fetal  Sureillance 
Standards which includes a minimum of 6 hours of taught training on CTG monitoring 
&  intrepretation.  WRP  are  supporting  the  introduction  of a  competency  based 
assessment for CTG  intrepretation.  Training compliance is being monitored through 
Maternity Improvement Board. 

3. There was unclear communication as to whether a category 1 or 2 caesarean 

section was required. 

The importance of ensuring the team communicate the level of urgency for caesarean 
section has been communicated to all staff via feedback on cases - newsletters and at 
clinical  review  meetings.  The  multidisciplinary team  attend  PROMPT training  on  a 
monthly basis which  has  a  clear focus  on  the  management of emergency clinical 
situations  with  clear team  communication.  Clinical  incident review  meetings  and 
multidisciplinary  reflection  sessions  gives  an  opportunity to  review clinical  decision 
making and communication in relation to the level of urgency of a caesarean section. 
Monitoring of the categorisation of caesarean section is included on the clinical audit 
plan for 2019/20. 

4.  NEWS chart and partograms were not completed, and there was a  poor 

standard of record keeping. 

The maternity services have commenced a  record keeping audit as part of the audit 
plan. The findings of the audit will be shared with all staff and actions taken where 
improvements  need  to  be taken.  The senior midwives  are  undertaking  assurance 
audits on the maternity wards monitoring the standards of records and completion of 
NEWS  charts  and  other risk assessments.  Any areas  identified  at the time  of the 
monthly assurance  audits  are  being  managed  at the  time  of finding  an  error or 
incomplete  record.  Clinical  Supervisors  for Midwives are  conducting  monthly group 
supervision sessions with a focus on the standard of record keeping. 

s.  There were insufficient staffing levels, and very high acuity, despite which 
there was no consultant attendance and the escalation policy was not used. 
There  was  evidence  that there  was  no  clear  line  of responsibility for 
identifying and ameliorating it. 

Staffing  has  significantly improved  since  August 2018 with  ongoing  recruitment of 
midwifery staff.  The merger of the two units has assisted  in managing any staffing 
shortfalls as we are no longer providing cover for two units. 

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 

 Midwifery and medical staffing are being reported on a  monthly basis via the Maternity 
Improvement Board.  We are currently undergoing a  Birth  Rate Plus Asessessment of 
our workforce needs in the new unit. The final  assessment report will  be available in 
September 2019. 

Consultant cover has increased significantly and the Health Board has recently recruited 
3  new consultants.  There  is 60  hour labour ward  presence on the labour ward  since 
the merger. 

There  is a  new escalation  policy and staff are  incident reporting times of high  acuity 
this  is  being  monitored  via  datix reporting.  There  is a  senior midwife  on  call  rota  to 
support staff with any concerns in clinical  practice out of hours and for concerns about 
escalation. 

Birthrate plus acuity system for labour ward  has been implemented  into the unit and 
staff are currently being supported to use this to support timely escalation. 

6.  The recent merger of the maternity units of Prince Charles and the Royal 
Glamorgan  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. 

As  part  of the  Organisational  Development  work  being  undertaken  a  Clinical 
Psychologist has been approved to assist in undertaking some targeted work with staff. 
Continued  monitoring  and  support  from  Human  Resources  is  also  in  place.  An 
improvement plan has been in place since September last year and is monitored by 
Welsh Government and the Maternity Improvement Board to ensure continued safety 
of the maternity department. 

I sincerely hope that this information  will  reassure you  that the  Health  Board  has 
learned  important lessons from  the  investigation  into the care  provided  to Jenson 
James Francis 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 Jenson for the failings identified. 

Yours sincerely 

rs V32> 

Greg Dix 
Acting 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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