Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0044, written 26 Feb 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 26 Feb 2020 |
|---|---|
| Reference | 2020-0044 |
| Deceased | Jack Postle |
| Coroner | Geoffrey Sullivan |
| Coroner area | Hertfordshire |
| Category | Child Death (from 2015) · Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | West Hertfordshire Teaching Hospitals NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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Signed by Geoffrey Sullivan Title Senior Coroner Jurisdiction Hertfordshire REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Maternity Quality & Safety Group Watford General Hospital (WGH) Clinical Director WGH: — | CORONER | am Geoffrey Sullivan Senlor Coroner for Hertfordshire 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.goy.uk/ukpga/2009/25/schedule/5/paragraph, http://www. legislation.gov.uk/uksi/2013/1629/pa made | INVESTIGATION and INQUEST The Chief Coroner directed that an investigation should take place Into the death of Jack Postle, a baby aged 6 days. Jack was delivered at WGH on the 29" September 2017 and died on 5/10/17 at Luton and Dunstable Hospital specialist neonatal unit. A hospital post-mortem was carried out and the cause of death was given as 1a) Severe Hypoxic Ischaemic Encephalopathy & Multi Organ Failure. A Form 100A was issued by Bedfordshire Coroner’s Service and registration and cremation then took place. Subsequently the family raised concerns with Bedfordshire and a Root Cause Analysis Investigation Report produced by West Herts Hospitals. On 25/04/2019 ! commenced an Investigation into the death of Jack POSTLE. The investigation concluded at the end of the inquest 18""- 19th February 2020. The cause of death provided by the pathologist: 1a) Severe Brain Hypoxic Ischaemic Encephalopathy 1b) Delayed Placental Maturation and Acute Chorioamnlonitis and Foetal Chronic Vasculitis. The conclusion: Jack Postle died as a result of an avoldable natural cause. The death was avoidable as there were two missed opportunities to provide care to Jack which if taken would likely have saved his life. During the course of the inquest, evidence was heard from multiple witnesses that the maternity unit did not have the capacity to care for the number of patients on the unit at that time. The delivery suite was consistently unavailable during Mrs Postle’s stay at the hospital which meant that the ARM (artificial rupture of membrane) procedure could not be performed. The evidence of (J (consultant obstetrician) that Mrs Postle was offered a caesarean section and that she declined was not accepted by the court. It was confirmed that at the time of the Inquest HB was on suspension and had been referred to the GMC. | CIRCUMSTANCES OF THE DEATH The circumstances of the death recorded at the Inquest: Jack Postle was to be delivered by induced labour at 40 weeks due to reduced foetal movements. On 23 September 2017 Jack Postle's mother was admitted to Watford General Hospital for induced labour. She remained there until the 26 September 2017. When she was discharged on 26 September 2017 she was Not given the option of a caesarean section and had this procedure been performed that day It Is likely that Jack would have survived. Jack Postle's mother returned to Watford General Hospital on 28 September 2017 with strong contractions, She was sultable for delivery by artificial rupture of the membrane (ARM) but the delivery suite was not available. Had Jack been delivered on 28 September 2017 It Is Ilkely he would have survived. On 29 September 2017 the delivery sulte was still not avallable for ARM. Jack Postie's heart rate was monitored during the day and was essentially normal until 09:58hrs when it dropped to unrecordable. The reading was noted by a mid-wife at 10:08hrs and an alarm call put out. The decision was made for an emergency caesarean section and Jack Postle was delivered at 10:36hrs. He was in a poor condition and was transferred to the specialist neo-natal unit at Luton and Dunstable Hospital. Despite treatment he died there on 5 October 2017. There were two missed opportunities to provide care to Jack which if taken would likely have saved his life, ORONER’S CONCERN: 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) That there is insufficient capacity at the WGH maternity unit to provide a safe level of care to patients. (2) That the guidance provided to consultants, for outlining options to an expectant mother, seek to limit the availability of caesarean section, even following failed Induction. Of the three options, LSCS Is the only one to Include the caveat ‘but not as first choice’. This caveat Is Included without reference to any other clinical considerations which might affect the appropriateness of the options. ( Para. 10 induction of labour including out-patient and use of intrapartum oxytocin, 1" September 2016, Version 3.1) [6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe that the Maternity Quality & Safety Group WGH and the Clinical Director WGH: [EEMhave the power to take such action. 7 | YOUR RESPONSE 7 You are under a duty to respond to this report within 56 days of the date of this report, namely by 2am April 2020, | the coroner, may extend the period. Your response must contain detalls of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action Is proposed. 8 | COPIES and PUBLICATION - } | have sent a copy of my report to the Chief Coroner and to the following Interested Persons: The parents of Jack Postle, | am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish elther or both Ina 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. 9 26/02/2020 Signature Geoffrey Sullivan
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.
r~1:b1 West Hertfordshire Hospitals NHS Trust Watford General Hospital Vicarage Road Watford Hertfordshire WD1 8HB ••• • teamwestHerts 3 June 2020 PRIVATE AND CONFIDENTIAL Mr G Sullivan Senior Coroner for Hertfordshire The Old Court House St Albans Road East Hatfield Herts AL10 0ES Dear Mr Sullivan Jack Postle - Regulation 28 Report I am writing to you in my capacity as Chief Executive of West Hertfordshire Hospitals NHS Trust (WHHT) to respond to the concerns you raised following the investigation into the circumstances surrounding the tragic death of Jack Postle, which led you to making the Regulation 28 Report dated 26 February 2020. The concerns raised were as follows: 1) 2) That there is insufficient capacity at the WGH maternity unit to provide a safe level of care to patients That the guidance provided to consultants, for outlining options to an expectant mother, seek to limit the availability of caesarean section, even following failed induction. Of the three options, LSCS is the only one to include the caveat 'but not as first choice'. This caveat is included without reference to any other clinical considerations which might affect the appropriateness of the options, (Para.10 Induction of Labour out-patient and use of intrapartum oxytocin, 1st September 2016, Version 3.1 ). The actions of the Trust are primarily focussed on improving the pathway that Jack's mother, - experienced at WHHT. The Trust recognises that these actions will not change what - happened, but it hopes that these actions will give Jack's family some comfort and reassurance that the Trust has learnt from his death and continues to do so to ensure that all patients at the Trust receive the highest standard of care. The Trust has developed a Prevention of Future Deaths Action Plan for 2020/21 , which I hope will provide assurance that the areas highlighted in your Regulation 28 Report are being adequately managed. The actions which the Trust has taken , and those actions which are currently in progress have been summarised below: • A baseline audit of the Induction of Labour pathway has been completed and was due to be presented at the Women's Governance and Divisional Governance meetings in March 2020. Unfortunately this was not possible due the Covid-1 9 pandemic and has been re-scheduled for presentation in June 2020; this data will under pin the Induction of Labour Guideline and pathway. • • • • • • Consultant job plans are being reviewed to ensure a dedicated consultant lead ward round will be undertaken on the Antenatal ward on a daily basis. The consultant will have oversight of all the women on the Antenatal ward and will ensure care plans are in place in event of any delays. The Induction of Labour Guideline is being updated to reflect changes in the process for induction to have Cervical Ripening as first line management and also to offer women induction of labour at 39 weeks with any episode of reduced fetal movements. This update will ensure the option for LSCS is given equal weighting when an induction of labour fails. A date for completion of this action will be set when the baseline data has been presented in June 2020. The Maternity Escalation guideline (2018) is being reviewed to ensure it is explicit about transfer from Antenatal ward to Delivery Suite. This should be complete by July 2020. The Maternity Service plans to introduce an Electronic white board as part of the Trust roll out program, to enable Delivery Suite to have a real-time overview of patients in all maternity areas. The service is working towards its implementation in September 2020. Our Director of Midwifery is working with the Local Maternity Services (LMS) to develop a Standard Operating Policy (SOP) for transferring women to maternity units within the LMS in cases of delay or lack of capacity. It is hoped this will be completed by in June 2020. A scoping exercise is to be undertaken to assess the possibility of a three bedded induction bay on the current Delivery Suite; however this is included in the acute redevelopment of West Hertfordshire Hospitals NHS Trust's estate. I had hoped that more of the actions in the improvement plan would have been completed by now, however there have been a number of challenges presented by the Covid-19 pandemic to business continuity within the Trust's maternity services, requiring alterations to be made to the patient pathways in response. Whilst governance activities were maintained throughout to provide assurance about quality and safety standards, some actions in the action plan have not been progressed as quickly as was intended, however many were considered as a high priority in the division and a number of key personnel have been working on them. The actions outlined in this letter will be scrutinised through our internal governance processes including: • • • • • Women's Governance meeting (Chair: The Obstetric and Gynaecology Clinical Directors and Director of Midwifery & Gynaecology Nursing); Divisional Governance meeting (Chair: Divisional Director); Quality & Safety Group (Chair: Chief Nurse); Quality Committee (Chair: Non-Executive Director) ; External scrutiny will be undertaken by our Clinical Commissioning group and the Care Quality Commission (CQC). The CQC will be updated regularly as part of relationship management meetings. The Trust would also be willing to provide Jack's family with regular updates (either directly or through their solicitors) on the progress that has been made, if they would find that beneficial. I hope that this response provides you with the assurance you require that the issues you have raised are priorities for the Trust but please do not hesitate to contact me if you require further clarification on any of the information provided. Yours sincerely Christine Allen Chief Executive tbmm1tment Gc1re t •
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