Elisa Fuller

NHS 
Gloucestershire Hospitals 
NHS Foundation Trust 

Alexandra House 
Cheltenham General Hospital 
Cheltenham 
Gloucestershire 
GL53 7AN 

12th  December 201 

Ms K Skerrett 
HM Senior Coroner for Gloucestershire 
Gloucestershire Coroner's Court 
Corinium Avenue 
Barnwood 
Glocuester GL4 3DJ 

Dear Ms Skerrett 

Elisa Fuller deceased 

I am writing in response to your letter dated 18 October 2019 in which you raised concerns arising 
from the evidence heard during this inquest. It is your view that there is a risk that future deaths will 
occur unless action is taken about these concerns. 

The matters of concern are: 

1.  Whether there is appropriate support and systems in place to encourage junior midwives and 

junior doctors to escalate any concerns they have to more senior colleagues 

2.  Whether there is sufficient understanding of the need to retain placentas post-delivery for a 

specified time period prior to disposal 

The Trust's responses are as follows: 

1. Whether there is appropriate support and systems in place to encourage junior midwives and  

junior doctors to escalate any concerns they have to more senior colleagues  

In addition to the training and practice which midwives and doctors undertake during their 
professional qualifying courses and degrees, the Trust provides the following events and 
tools for the support and ongoing education of clinical colleagues about the importance and 
clear expectations of the need for escalation of all concerns which have the potential to 
impact upon the safety of patients in our care: 

Chair: Peter Lachecki 

Chief Executive: Deborah Lee 

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I.

Mandatory Update day - Midwives 

The midwives mandatory update day for 2018 - 2019 included a focussed presentation from 
the Divisional Risk Manager on lessons learned from recent inquests and clinical incidents. 
The poster highlights five situations where practice has been improved through embedding 
learning from incidents. Two of these situations ('Syntocinon' and 'documenting') included 
reference to the importance of escalating concerns. Attendance level for midwives was 
94.4% for the year. 

• 
• 

Enclosure 1 — Midwives Mandatory Update Day Programme 2018/2019 
Enclosure 2 — Poster presented by Risk Manager 

II.

SBAR referral tool - Midwives and Doctors 

The escalation which is encouraged should be undertaken in the form of the 'SBAR' 
(Situation/Background/Assessment/Recommendation) referral tool. The tool suggested on 
Enclosure 2 for the 'Documenting...' case is the 'RSVP' referral tool. This has been replaced 
in the Trust by the 'SBAR' referral tool, explained in Enclosure 3. In this tool, the reasons for 
the referral i.e. the escalation and the plan for review of the patient (as a result of the 
escalation) are formalised in the 'S' and 'R' parts of the tool. 

This is a structured referral tool widely used nationally, across maternity services. 

• 

Enclosure 3 - SBAR (Situation/Background/Assessment/Recommendation) referral 
tool 

III. Rotation Day programme - Midwives 

This is a programme directed at midwives new to the Trust, recently qualified midwives, 
those returning to work after a break or midwives moving to work in a new clinical area. 
These colleagues are required to attend this programme twice during their `preceptorship 
period'. Preceptorship is the period immediately following qualification, and extra support 
given in that period is intended to guide the newly qualified practitioner through a successful 
transition from student status, and to develop their practice through a structured program of 
support, lasting between 18 months and 2 years. This teaching day covers professional 
issues including escalation, documentation, time management and professional behaviour 
such as assertiveness and communication. 

• 

Enclosure 4 - Rotation Day programme June and November 2018; June and 
December 2019 

IV. Practical Obstetric Multi-Professional Training — PROMPT' - Midwives and Doctors 

This is an emergency skills study day attended by both midwives and medical staff. The 
PROMPT day included a session looking at 'human factors' i.e. the relationship between 
human beings and the systems with which they interact and a 60 minute presentation on 

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'resilience' both of which can impact on a clinicians ability and attitude to escalation.  
Attendance for the year was midwives 96.4% and obstetric doctors 80.6% 

All drills are delivered with a focus on team work and effective communication. The course is 
endorsed by the Royal College of Midwives (RCM) and the Royal College of Obstetricians 
and Gynaecologists (RCOG) with further information available from on the PROMPT website 
and RCOG. 

• 

Enclosure 5 — PROMPT training programme for 2018-2019 

V.

Newborn Early Warning Observation charts — documented by Midwives, consulted by 
Doctors 

The New Early Warning Observation Chart for Newborn Infants (NEWS chart) has been in 
use in clinical areas for a number of years and has escalation criteria clearly presented on 
the reverse of the chart. This has recently been updated as the Newborn Early Warning 
Trigger and Track chart (NEWTT chart) and includes details of observation frequencies and 
conditions that trigger an immediate clinical review.. The specific question as to whether the 
infant is exhibiting 'grunting' is made clearer on the first page; grunting is a sign of respiratory 
distress and was a feature of this case as it should have been effectively escalated. 

The NEWTT chart will be launched in all relevant clinical areas on December 30th  2019. 

• 
• 

Enclosure 6 — Newborn early Warning Observation Chart 
Enclosure 7 — Newborn early Warning Trigger and Track chart 

2. Whether there is sufficient understanding of the need to retain placentas post delivery 

At the time of Elisa's birth, the placenta was not retained as it appeared that she was born in 
good condition. Current guidelines on retention for pathological examination (dated October 
2019) indicate that on the basis of prematurity (32 to 36+6 weeks) it "may be desirable" to 
refer placenta for examination (Appendix A). Elisa was born at 36 weeks, marginally 
premature, but also with none of the conditions that that require 'essential' referral for 
placental examination (Appendix A). 

The policy in place at the time of Elisa'a death required placentas to be retained only if 
certain criteria were met at the time of birth. Unfortunately Elisa's placenta was not retained 
as concerns did not become apparent until some hours after birth 

However, in response to the evidence heard at the inquest from the pathologist that his 
determination of the cause of death was considerably limited by the absence of the placenta, 
the Trust has revised its policy on retention of placentas so that all placentas are retained for 
24 hours after birth, and are sufficiently identified so that they can be reliably retrieved in the 
event that there are any subsequent adverse clinical events affecting the baby. 

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The Trust's proposed process for retention of placentas is as follows: 

o 

o 

At birth, the placenta is placed in a bag and labelled with the patient's details on a 
sticker. Patient details are also written on the bag with an indelible pen to safeguard 
against the loss of the patients identification sticker 

The bagged placenta is placed inside the usual human waste disposal container 
(usually to a maximum of 5 placenta) the lid is NOT sealed. 

o  When the 5`' or last placenta is added to the waste disposal container, a sticky label is 
placed on the lid with the date and time of when the lid is due to be sealed shut ie 24 
hours after the last placenta is placed in the container . 

o 

The lid is closed securely 24 hours after the addition of the last placenta. The container 
is then disposed of. 

There is no national guidance on how long we should retain a placenta, but a reasonable time 
might be 24 hours, after which before the waste disposal container can be removed in the usual 
way. 

This new procedure is in place in the Trust, supported by teaching sessions on the delivery suite 
and birthing units. A brief guide to undertaking this procedure, and relevant signage to assist 
colleagues, has also been developed. The formal Trust policy has yet to be ratified but it is hoped 
this will be finalised in early 2020. 

• 

Enclosure 8 — Tissue pathway for histopathological examination of the placenta 
(RCOG October 2019) 

Finally, I can also add that as a result of the inquest into Elisa's death, the following additional 
review and learning has taken place, for the clinical staff involved, and for any interested 
colleagues: 

a) 

There has been a 'debrief 'with the midwifery staff to further explore and understand barriers 
to escalation 

b)  A 'Black Box' event is planned for January 2020 led by the Trust Safety Department. This is 
a bespoke learning event (originating in the risk management processes of the aviation 
industry) and will focus on how to better understand and improve multi professional learning 
from incidents. The aim is to further explore barriers to escalation and what we could do to 
improve escalation in all care settings across the Trust. 

c) 

A "What Matters to you?" event took place on 6th  December 2019 to provide an opportunity 
for staff to further consider and address issues in the working environment that impact on 
professionals' performance e.g. understanding the roles and responsibilities of the whole 
team, the need for kind and respectful communication and support from core staff for less 
experienced staff working in specialist areas such as delivery suite. 

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I am confident that there has been considerable reflection, learning and changes in practice as a 
result of Elisa's death all of which will significantly contribute to the reduction in the likelihood of 
such an incident occurring in the future. 
I hope this response adequately answers your questions but please do not hesitate to return to me 
if you require any further information 

Yours sincerely 

Deborah Lee 
Chief Executive 

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