Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0356, written 5 Sep 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 5 Sep 2019 |
|---|---|
| Reference | 2019-0356 |
| Deceased | Tillie Spencer-Adams |
| Coroner | Geoffrey Sullivan |
| Coroner area | Hertfordshire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Child Death (from 2015) |
| 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.
Signed by Geoffrey Sullivan
Title HM Senior Coroner
Jurisdiction Hertfordshire
i
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT !S BEING SENT TO: Chief Executive, Medical Director, Clinical Director Paediatrics, East
and North Hertfordshire NHS Trust
CORONER
Geoffrey Sullivan, HM Senior Coroner for Hertfordshire
uw
"| INVESTIGATION and INQUEST
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,
http://www. legislation.gov.uk/uksi/2013/1629/part/7/made
On 10/04/2019 | commenced an investigation into the death of Tillie SPENCER-ADAMS. The Investigation
concluded at the end of the inquest 3rd September 2019.
Medical cause of death: Unascertained
Circumstances:
On the 18th June 2018 at around 08:45hrs Tillie Spencer-Adams was found unresponsive by her mother
next to her In bed. Tillie was lying on her back, on her mother's bed with her arms above her head, her
lips were blue. An ambulance was called and paramedics attempted CPR at the scene. Tillie was then
taken to Lister Hospital where advanced !Ife support continued for around 30 minutes but Tillie could not
be revived and her death was confirmed at 10:15hrs. In the period immediately preceding her death
Tillie was co-sleeping with her mother. This is a recognised risk factor in infant death but it is not clear
whether this caused the death.
Conclusion: Sudden Unexpected Death in Infancy (SUDI)
CIRCUMSTANCES OF THE DEATH
The matters outlined below were not found to have caused or contributed to the death but do give rise
to the relevant concern.
During the course of the investigation it was discovered that on 04/05/18 the mother was Involved in a
road traffic collision (no third party) and rolled the car, Tillle was In her car seat at the time.
Tillie was checked at Lister Hospital and no Injuries were found apart from small mark on her clavicle
from the seatbelt. She was discharged the same day.
Coroner Service, The Old Court House, St Albans Road East, Hatfleld, Hertfordshire AL10 0ES
Tel: 01707 292 707 | E: coroner.service@hertfordshire.gov.uk
The post mortem examination on 02/07/19 showed Tillle had sustained fractures to the distal right
radius and ulna. Given their close proximity it is likely that these occurred together. In dating the
fractures it Is plausible that they happened as a result of the reported road traffic collision on
04/05/2018. It Is also likely that an old sub-scalp haemorrhage and the old subdural haemorrhage also
relate to this road traffic collision.
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) On the 4/5/18 the deceased attended the Lister Hospital following a road traffic collision in which she
is IIkely to have suffered serlous injuries (fractures and head injuries) which appear to have been
overlooked.
| ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe you, Chief Executive, Nick
Carver; Medical Director Michael Chilvers and Cltnical Director Paediatrics, Amitabh Gite of East and
North Hertfordshire NHS Trust 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
31 October 2019. I, the coroner, may extend the period.
Your response must contain detalls of action taken or proposed to be taken, setting out the timetable for
actlon. 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: the LOCAL
SAFEGUARDING BOARD (where the deceased was under 18)].
lam also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish elther or both in a complete or redacted or summary form. He may senda
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.
') 05/09/2019
Slgnature -
Geoffrey Sullivan HM Senior Corondr Hertfordshire
Coroner Service, The Old Court House, St Albans Road East, Hatfield, Hertfordshire AL10 OES
Tel: 01707 292 707 | E: coroner.service@hertfordshire.gov.uk
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.
East and North Hertfordshire INHS| NHS Trust Direct Line: 01438 284049 ; 5 Lister Hospital Our Ref: NC/SN Coreys Mill Lane Er: Stevenage Herts SG1 4AB 30" October 2019 Tel: 01438 314333 Mr G Sullivan Senior Coroner for Hertfordshire The Old Courthouse St Albans Road East Hatfield Hertfordshire AL10 OES Dear Mr Sullivan Tillie Spencer-Adams | am writing in response to your regulation 28 report to prevent future deaths, dated 5" September 2019, regarding the above named. !| was extremely saddened to learn of the circumstances of Tillie’s death on 18" June 2018. | am grateful for you taking the time to meet wii Medical Director, an fii Clinical Director for Paediatrics, to discuss the regulation 28 report. Whilst | know we provided you with a report fron MIE Consultant Paediatrician, in advance of the inquest, this was only in relation to the care provided on 18" June. It was most unfortunate that my staff were not able to assist you further either prior to the Inquest with a report covering the care provided on 4" May 2018 or at the Inquest in person. | am aware that the post-mortems found Tillie to have sustained fractures to her distal radius and ulna along with an old sub-scalp haemorrhage and old subdural haemorrhage and | note that your letter states it is plausible that these happened as a result of the road traffic collision on 4" May 2018. The contents of your letter were of grave concern to me and therefore | aske: Clinical Director for Paediatrics, to review the care provided when Tillie attended on 4" May 2018. Tillie was brought in by ambulance at approximately 01.00hrs; the ambulance sheet records her only injuries to be a reddening to right collar bone. On arrival in the Emergency Department she was assessed by the triage nurse who documented the red mark on her clavicle along with a red mark on her head and queried some mild swelling to her right eye. This same Nurse completed an information sharing form in view of Tillie’s mother having been found to be driving under the influence of alcohol and on that she noted red mark on right shoulder and head. Tillie was then moved to the Children’s Assessment Unit where she was reviewed by a Paediatric Registrar; this review included taking a detailed history along with a full physical examination. A 2cm linear red mark was found on her right clavicle and documented in the Chief Executive: Mr Nick Carver Trust Chair: Mrs Ellen Schroder medical records. The medical records specifically state that there was no facial bruising seen and no other bruising noted anywhere else on her body. Tillie’s case was discussed with the Paediatric Consultant who advised that there was no requirement for a CT head scan as there was no external visible injury but to admit her for observation. In view of the presenting history, Tillie remained under 1 hourly neurological observation and both the Police and the Trust made a social services referral. Tillie was reviewed by a Paediatric Consultant on the ward round the following morning. This review included a review of the presenting history and events overnight along with a detailed physical examination. The notes from that examination record that she was alert, active, good tone, handling well. The only injury noted is a linear red scratch mark on right mid- clavicular line. She was noted to be a ‘well baby’. There was no indication from that review that there were any concerns about either her arm or a head injury. At approximately 11am Tillie was transferred from the Children’s Assessment Unit to Bluebell Ward. The handover document records the only injury to be a red mark on her clavicle. Whilst the triage nurse in ED noted a red mark on Tillie’s head, this was not observed by either of the Paediatric doctors who reviewed her, nor any of the Paediatric nurses. In addition, Tillie did not display any red-flag symptoms indicative of a head injury. Thus, in line with NICE Guidance, there was no indication to perform a CT head scan. Equally there were no external signs of any injury to her right forearm, nor did Tillie appear to be in any discomfort whilst in ED or the Paediatric unit. She did not require any analgesia and the medical records indicate that she was settled throughout the admission. BB has discussed the case with the East of England (EoE) trauma network who agreed that in the absence of clinical concerns, there were no requirements for this child to be subjected to further imaging or investigations. For reference they suggested referring to the EoE trauma network guidelines which are aligned with The Royal College of Radiologists guidelines for trauma in children. Please find links below; http:/Awww.eoetraumanetwork.nhs.uk/clinicians/trauma-east-manual-of-procedures-and- operations hitp://www.eoetraumanetwork.nhs. uk/docs/default-source/trauma-east-manual-of- procedures-and-operations/tempo-05-e-i-emergency-department-paediatric-major-trauma- imaging-decision-tool.pdf?sfvrsn=2 Whilst | recognise the contents of your regulation 28 report, | hope the above explanation assures you that when Tillie attended the Trust on 4" May 2018 she was treated appropriately and in line with national guidance. There was no indication to the clinicians at that time that Tillie had any injury to either her forearm or her head. We have stringent clinical governance measures in place to prevent such incidents from occurring. Our Paediatric team are committed to providing the best possible care for children and young people in our area and we continually strive to improve the services available. Yours sincerely “Nick Carve Chief Executive Chief Executive: Mr Nick Carver Trust Chair: Mrs Ellen Schroder
See every Prevention of Future Deaths report matching Hospital Death (Clinical Procedures and medical management) related deaths, 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.