Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0174, written 28 May 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 28 May 2019 |
|---|---|
| Reference | 2019-0174 |
| Deceased | Maia Strachan |
| Coroner | Karen Dilks |
| Coroner area | Newcastle Upon Tyne |
| Category | Child Death (from 2015) · Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Northumbria Healthcare NHS Foundation 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.
Karen Dilks Senior Coroner for the City of Newcastle upon Tyne REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Sir James Mackey, Chief Executive of Northumbria Health Trust, North Tyneside Hospital, Rake Lane, North Shields, Tyne & Wear, NE29 8NH 1 | CORONER | am Karen L Dilks, Senior Coroner, for the Coroner area of the City of Newcastle upon Tyne 2 | 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. 3. | INVESTIGATION and INQUEST On 10 July 2017 | commenced an investigation into the death Maia Hazel Ann Strachan born on 6 July 2017 and died on the 7 July 2017. The investigation concluded at the end of the inquest on 17 April 2019. The conclusion of the inquest was: Medical Cause of death: 1a. Hypoxic Ischaemic Encephalopathy 1b. Complication of Shoulder Dystocia secondary to Macrosomia 2. Maternal Diabetes Narrative Conclusion: Died due to complications of shoulder dystocia to which missed opportunities to reduce the risks of and diagnose severe foetal macrosomia contributed. CIRCUMSTANCES OF THE DEATH Maia Hazel Ann Strachan was born on the 6 July 2017. Her mother suffered from Diabetes and High Body Mass Index. Her Diabetes was uncontrolled before the pregnancy and in its early stages. This increased the risk of Foetal Macrosomia and consequently the risks of delivery. An ultrasound scan was performed on the 21 June 2017. The images were suboptimal, an incorrect formula used to calculate foetal weight and femur length inaccurate. This resulted in underestimation of foetal weight and a missed opportunity to plan Maia’s delivery by Caesarean Section. A plan for induction of labour was implemented on the 4 July 2017. At approximately 10am on the 6 July 2017, an opportunity was missed for delivery by Caesarean Section at mother’s request. Maia’s delivery was thereafter complicated by Shoulder Dystocia and prolonged attempts to deliver her which led to Hypoxic Ischaemic Encephalopathy and her death within the Royal Victoria Infirmary, Newcastle upon Tyne on 7 July 2017 Maia was severely Macrosomic weighing 5.1 kilograms at birth. On the balance of probabilities, Maia would have survived if delivered by Caesarean Section. 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 could 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 ability to store sequential scan data specific to each patient and provide alerts to the Sonographer. This would facilitate comparison and prompt further investigation potentially altering a patient’s care plan and outcome. The Trust's plan to procure software to facilitate the above should be urgently implemented. (2) Asystem of joint obstetric and diabetic care operates without the facility for clinicians to access patients’ obstetric and diabetic records whether manually or electronically. Accessibility is essential to inform clinical decisions and should be urgently addressed (3) Joint Decision Making: - Provision of advice and explanation of the risks of pregnancy and the risks/benefits of vaginal delivery or by Caesarean Section are essential to ensure informed decision making. The Trust should draft and implement a clear and comprehensive Local Joint Decision Making Policy/Protocol. (4) Foetal Scalp Electrode: The use of Foetal Scalp Electrodes (FSE) provide critical information in respect of foetal distress and the time implications thereof. The Trust should draft and implement a clear and comprehensive Local Policy/Protocol for FSE use. (5) Suboptimal Documentation: The Trust should implement a robust training and audit plan to address the risks of this occurring in the future. (6) The Findings and Conclusions of (independent Expert Witness): A redacted copy of HE <0 and conclusions should be circulated to all obstetrics and gynaecology staff (both nursing and medical) and all midwives. 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. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 23 July 2019. |, 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 and to the North Tyneside Local Safeguarding Board. | have also sent it to [J who may find it useful or of interest. Lam also under a duty to send the Chief Coroner a copy of your response. 9 | 28 May 2019 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. ss
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.
INHS' Northumbria Healthcare NHS Foundation Trust Patient Services and Quality Improvement Northumbria House Unit 7/8 Silver Fox Way Cobalt Business Park Newcastle upon Tyne NE27 0QJ 3 Direct Line: (0191) 203 1356 Email: claims. patientservices@northumbria-healthcare.nhs.uk Our ref: 17/18.Ing.11 Your ref: = KLDAWRD/STRACHAN/3024 22 July 2019 HM Senior Coroner Mrs Karen Dilks Newcastle upon Tyne Coroners Civic Centre Barras Bridge Newcastle upon Tyne NE1 8QH Dear HM Senior Coroner Mrs Dilks Inquest into the Death of Maia Hazel Ann Strachan On 17 April 2019 you held an inquest into the death of Maia Hazel Ann Strachan in which you concluded a narrative conclusion advising that Maia Strachan died due to complications ‘of shoulder dystocia to which missed opportunities to reduce the risks of and diagnose severe fetal macrosomia contributed. You acknowledged that actions had been taken by the Trust in respect of the issues identified in this case; however you had a number of concerns that remained outstanding and which you wished to be drawn to the attention of the Trust, which are details below along with our response, as follows: 1. There was evidence of sub-optimal documentation in the medical notes and you therefore require information from the Trust as to how this issue will be addressed by midwives and Doctors. Current training around the required standard for documentation has been reviewed and is provided. as part of the PROMPT annual training for all team members including midwives and obstetricians. The content of the training is informed by the findings of a recently completed documentation audit. This audit has until recently been completed annually however this has been superseded by a recent agreement within the Surgical Business Unit for an ongoing monthly audit of a specific number of notes in each speciality. There will be a quarterly report generated and presented to the Board, the themes and learning will be shared with the wider MDT team and this will also influence the training around documentation. ’ You raised concern about the midwifery care in the second stage of labour; and planned to share a redacted copy of the export report provided by Dr Sparey for circulation to inform future practice. Thank you for sharing the redacted report which | can confirm has been shared with all Obstetrics & Gynaecology staff, including midwives to inform future practice. You considered the issue of reporting a stillbirth, stating that it was expected in future that all stillbirths would be referred to a Coroner and that whilst this is not currently mandated this is likely to change. You therefore outlined your expectation that any birth involving potential and avoidable intrapartum events should be reported to or at least discussed with a coroner. You anticipate that stillbirths will require an independent review initially by the medical examiner and subsequently by the coroner and will therefore provide an increase in investigations. You advise that you plan to contact the Trust directly to advise of the need for Coronial input into training in anticipation of additional stillbirth inquests. The Trust has recently appointed medical examiners and discussions are in progress to identify whether there is a requirement to include them into the current pathways following bereavement in maternity services. Any further requirement to notify the Coroner of any stillbirth would also be incorporated into local pathways. We look forward to further discussions with you regarding Coronial input into training. In addition to this the Healthcare Safety Investigation Branch (HSIB) has been asked by NHS Improvement to undertake independent investigations into cases where the inclusion criterion for Each Baby Counts has been met. The Trust was included in the roll out of this reporting going live in March 2019. The criterion for reporting cases to HSIB includes but is not limited to: All babies born at or after 37+0 weeks gestation following labour with the following outcome: e Intrapartum stillbirth: when the baby was thought to be alive at the start of labour but was born with no signs of life. This includes when: « Labour'was diagnosed by a healthcare professional. This includes the latent phase of labour, i.e. less than 4cm dilatation The mother called the unit to report any concerns of being in labour, for example (but not limited to) abdominal pains, contractions or suspected ruptured membranes The baby was thought to be alive at induction of labour The baby was thought to be alive following suspected or confirmed premature ; = rupture of membranes (PROM). e Early neonatal death: when the baby died within the first week of life (i.e. days 0-6) of any cause 2 | hope this response is sufficient to address the additional concerns you raised and provides you with assurances you require. ' If | am able to assist you further, please do not hesitate to contact me. Yours sincerely Marion Dickson’ a. Executive Director of Nursing and Midwifery/Chief Operating Officer (Surgery) On behalf of Sir James Mackey, Chief Executive
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