Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0190, written 12 Apr 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 Apr 2019 |
|---|---|
| Reference | 2019-0190 |
| Deceased | Archie Grieves |
| Coroner | Terrence Carney |
| Coroner area | Gateshead & South Tyneside |
| Category | Child Death (from 2015) · Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Gateshead Health NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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.
Terence Carney
Solicitor
Senior Coroner
Gateshead & South Tyneside.
35 Station Road
Hebburn
Tyne & Wear
NE31 ILA
Tel: 0191 483 8771
Fax: 0191 428 6699
Regulation 28 — Report to Prevent Future Deaths
This Report is being sent to:
Chief Executive, Gateshead Health NHS Foundation Trust
Medical Director, Gateshead Health NHS Foundation Trust
Coroner
Tam Terence Carney, Senior Coroner for Gateshead & South Tyneside.
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.
http://www. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www. legislation. gov.uk/uksi/20 13/1629/regulation/28/made
http://www. legislation.gov.uk/uksi/2013/1629/regulation/29/made
Investigation & Inquest
On 9 June 2017 I commenced an investigation into the death of ARCHIE RAY GRIEVES, aged 2
HOURS 20 MINUTES. The investigation concluded at the end of the inquest on 157 March 2019.
The conclusion of the inquest was :
An avoidable neonatal death following shoulder dystocia, opportunities having been missed both
during antenatal care and at time of delivery to identify and implement appropriate and effective plans
to provide for a safe and successful delivery of the child
Circumstances of the Death
The deceased was born on the 24" May 2017. There was a complicated delivery in that shoulder
dystocia was identified. He was delivered but showed no sign of life initially. A while after he did
show signs of life and was taken to the special care baby unit where he died a very short time after.
Coroners 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 I my statutory
duty to report to you.
The matter of concern are as follows:-
This was an avoidable neo-natal death of a macrosomic baby resulting in shoulder
dystocia and a consequential 8 minute delay from delivery of the baby’s head to the
delivery of the body which resulted in significant hypoxia.
The Inquest process identified a number of missed opportunities both ante-natally
and at the time of pre delivery assessment and delivery.
1. The mother of this child presented for an initial booking appointment on the 6
October 2016. Discussions at this stage identified the possibility she was about the
12% week of her pregnancy. She was identified as low risk. Routine scans
examinations and appointments followed.
2. At the 26t week it was determined that the mother’s BMI was above 30 . The
fundal height was above the 90 centile and that there was a concern that she may
have gestational diabetes. .
3. A glucose tolerance test was commissioned. The test request did not identify the
patient was pregnant. The result was consequently wrongly interpreted as normal.
4, The mother was not referred to a Consultant lead Obstetric examination and
assessment when issues and concerns would have been identified both as to her
presentational weight and the potential consequential size of the baby.
5. A subsequent test apparently indicated no diabetes and a determination that the ante
natal care should follow a normal pathway
6. At the 34t week fundal size continued to be identify the baby’s development as
outwith the 95% centile and consequently on the basis of the Trust’s own guidelines
this mother should have been referred also to Consultant Obstetric care.
7. Fundal size measurements continued into the 40" week of pregnancy outside the
curve.
8. No additional planning for pre delivery/delivery was engaged and this mother was
continued on a normal pathway towards delivery apparently planned between the
40% and 42nd week,
9. In the absence of Obstetric care effective planning opportunities were missed to
consult and counsel this mother on the mode and time of delivery. In particular no
consideration was given to the possibility of an induced or caesarean birth or
delivery of this child at the 37%/38% week avoiding increases in baby’s weight and
recognisable risks at the time of delivery of a larger baby.
10.On presentation on the 24 May 2017 in labour this mother was received within the
Delivery unit as a low risk delivery and no review was undertaken of her earlier
management and care either because of the assumption of the appropriateness of
her ante natal care together with a conclusion which identified her as simply low risk
and/or because there was no meaningful interrogation of her records. In particular
the significance of the Growth Chart present within those records with its all too
apparent fundal height measurement was misunderstood/misinterpreted or
overlooked as to its relevance.
11.Specifically during the period from 1.30 pm to 6.30 pm, in the absence of any
meaningful interrogation of her records the assessment of the mother on
presentation in the delivery suite failed to identify any risk she presented in view of
her personal bodymass or the size of her baby. It was determined it was appropriate
that she deliver in the Birthing Pool. The only considerations as to Pool use were
practical considerations around availability, staffing and an adjacent delivery room.
12.As a consequence of the lack of any alert to the risks that this lady presented no
consideration was given to the potential risks identified within the Trusts own
protocols relevant in the case of this lady and her child
13.An opportunity was missed to guide the mother away from a pool birth because of
those risks and to an alternative method of delivery with appropriate levels of
analgaesic support commensurate with her needs and anxiety
14.No risk assessment was made preparatory to the delivery of a macroscopic baby and
the heightened risk of shoulder dystocia
15.No plan was prepared guidance or assistance sought to facilitate a safe birth in a safe
environment and with the appropriate level of skilled staff on hand or available
16. Further evidence adduced indicated there was an apparent misunderstanding and/or
misinterpretation even level of conflict amongst Obstetric Consultants as to the
Trust’s own guidance on potential large baby development risks and the alternative
strategies to be followed and in a timely manner for the safe delivery of such
children.
17.Evidence was received that large babies were not identified as such a great concern as
small babies, that mothers of the latter would be monitored and advised and quite
properly so but larger babies size being more indicative of the healthy presentation
and more positive outcome, were accordingly considered less at risk
18.Obstetric approach differed depending on the Consultants personal policy and
consequently a more cohesive leadership Departmental approach was potentially
missing
19.In addition it was acknowledged that there was a study nationally , currently being
undertaken with reference to the management of larger babies and their birth. At
the time of this matter and indeed now the outcome of that study was still awaited
and no definitive guide appears to exist within the Trust.
20.The consequences of this lack of cohesive policy lends itself to a lack of clear
understanding and consistent approach which should be the guideline in all cases
and for the benefit of all staff both medical and nursing.
21.There should be no presumption of low risk now and medical/midwifery teams
should proactively interrogate records and assess delivery options not simply on the
basis of practical consideration - room availability, staff as was the case here but on
the requirements of the Protocol and the patients medically identifiable/identified
tisk profile.
22.A comprehensive Training review involving all staff policies and protocols is clearly
indicated. New technology and method should be embraced both in the training
process but also as an ongoing aid
23.The missed opportunities in this matter would have been avoided if significant
findings had been “red flagged” within mother’s records. A significant finding
being something which is potentially likely to impact on the management and care of
the patient at some stage during their journey and more particularly one identified as
factors in the policies and practices of the Trust determined to ensure the safe care of
the patient and in this case mother and baby.
24.Such red flags in this matter would and should have highlighted :
a) A heightened BMI
b) A Fundal height above and outwith the gestational norm
|
|
|
:
H
|
i
:
if
i
:
25.As an added aid to safe management and care such “red flags” should cross reference
specific Policies/protocols where such issues contra- indicate certain strategies
(birthing pools and increased BMI large baby) or alert for protective planning and
preparation
26. The fact that the Growth Chart in this matter :-
a) demonstrated the baby to be large for his gestational age and
b) there was an apparent lack of understanding appreciation /conflict as to the
significance of The Chart as well as
¢) an inability to interpret The Chart by nursing and medical staff and
d) more importantly a lack of awareness that such a measure should in accordance with
established Trust policy have lead to a Obstetric referral and consultation,
together leads to :-
A requirement that that policy be immediately revisited - any contradictions be
reconciled and resolved and all staff trained not only as to the validity nature and
implication of the policy but an urgent need for Trustwide implementation.
Action Should be Taken
In my opinion action should be taken to prevent future deaths and I 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 7"
June 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 & Publication
have sent a copy of my report to the Chief Coroner and to the following Interested Persons, |
» Ward Hadaway {and to the Local Safe-Guarding board (where the deceased was under
18)}.
Tam 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.
Date: 12" April 2019
Senior Coroner — Gateshead & South Tynféside
See every Prevention of Future Deaths report matching Gateshead Health NHS Foundation 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.