Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0070, written 11 Mar 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Mar 2020 |
|---|---|
| Reference | 2020-0070 |
| Deceased | Rifky Grossberger |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Child Death (from 2015) · Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: Prevention of Future Deaths report
Rifky GROSSBERGER (died 05.08.19)
THIS REPORT IS BEING SENT TO:
1. Professor Stephen Powis
National Medical Director
NHS England & NHS Improvement
Skipton House
80 London Road
London SE1 6LH
2. Dame Professor Donna Kinnair
Chief Executive and General Secretary
Royal College of Nursing
20 Cavendish Square
London W1G 0RN
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 6 August 2019, one of my assistant coroners, Sarah Bourke,
commenced an investigation into the death of Rifky Grossberger, aged
1 year. The investigation concluded at the end of the inquest on 14
January 2020. I made a determination at inquest that death was the
result of an accident.
I apologise for the delay in sending this prevention of future deaths
report. I had some difficulty in identifying the correct recipients.
1
It is my hope that by writing to you both, there is the potential to help
parents, carers and their babies across the country, not just locally.
4
CIRCUMSTANCES OF THE DEATH
Soon after 6pm on Wednesday, 31 July 2019, Rifky Grossberger stood
up in her cot and became entangled in a metal blind cord. Her mother
found her with it around her neck shortly afterwards and called
emergency services. She was resuscitated but died five days later. Her
medical cause of death was:
1a hypoxia
1b asphyxia
5
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.
Before Rifky became entangled in the metal blind cord, her parents were
unaware of its potential danger. The instruction leaflet provided with the
blinds had long since been discarded and so they did not see this.
I asked Rifky’s mum what would have been the most useful source of
warning, and she thought the leaflets she was given after Rifky was born,
and also her healthcare professionals.
Professor Powis, I have attempted to locate a national leaflet, but so far
unsuccessfully. It occurs to me that you may have input into local
leaflets.
the midwives and district nurses who look after new
mums and their babies are well placed to offer advice, but may need a
reminder to warn of this particular danger.
I appreciate that new parents receive a lot of paperwork and a lot of
information generally. That can be overwhelming of course, but I am
sure that methods could be devised of delivering such safety advice that
would make this situation less likely in the future.
The NHS website would also be a good place to provide this information,
though it might not have assisted in this case, as Orthodox Jewish
families do not necessarily access the internet.
2
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that you have the power to take such action.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date
of this report, namely by 11 May 2020. 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.
8
COPIES and PUBLICATION
I have sent a copy of my report to the following.
HHJ Mark Lucraft QC, the Chief Coroner of England & Wales
Professor Chris Whitty, Chief Medical Officer for England
Hackney Safeguarding Children Board
Hackney Child Death Overview Panel
Health and Safety Executive
Rifky’s parents
and
I am 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 Senior Coroner, at the time of your response,
about the release or the publication of your response by the Chief
Coroner.
9
DATE SIGNED BY SENIOR
CORONER
11.03.20
3
2 responses 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.
Coroner ME Hassell Senior Coroner Inner North London St Pancras Coroners Court Camley Street London NC1 4PP Dear Ms Hassell Professor Stephen Powis National Medical Director NHS England & NHS Improvement Skipton House 80 London Road London SE1 6LH 27th May 2020 Re: Regulation 28 Report to Prevent Future Deaths – Rifky Grossberger who died on 5 August 2019. Thank you for your Regulation 28 Report (hereafter the ‘report’) dated 11 March 2020 concerning the tragic death of Rifky Grossberger on 5 August 2019. Firstly, I would like to express my deep condolences to Rifky’s family and all those touched by her death. Your report concludes that Rifky’s death was a result of an accident. Her medical causes of death were hypoxia and asphyxia. Following the inquest, you asked NHS England and Improvement (hereafter ‘NHSEI’) to address your concern regarding the need to find methods of delivering safety advice in an easily accessible format. This could be in the form of local and national leaflets to provide parents with the safety advice they need to look after their new born baby. There is advice available on the NHS Choices website on ligature risks https://www.nhs.uk/conditions/pregnancy-and-baby/baby-safety-tips/ and it specifically mentions blind safety. You also asked NHSEI to address your concern around the need for healthcare professionals such as midwives and district nurses who look after new mums and their babies to be reminded of this particular danger. We have consulted with Public Health England (hereafter ‘PHE’) who have advised that the national Healthy Child Programme (HCP) published by the Department of Health and Social Care, the universal public health programme for 0-19 year olds and their parents/carers, recommends that home safety information is discussed with families from birth and throughout the first 5 years. The Healthy Child Programme (0- 5) is led and delivered by Health visitors. Health visitors are specialist public health nurses, who are the lead professionals working with children 0-5 years. They deliver NHS England and NHS Improvement evidence based public health interventions and are skilled in identifying issues early, determining potential risks, and providing early intervention to prevent issues escalating. Health visitors deliver the five mandated health reviews which include: • 28/40 weeks of pregnancy • 10-14 days post birth • 6-8 weeks • 1 year • 2.5 years PHE sets out more specific guidance on the role of the health visitor in the Six High Impact Areas which support local delivery of the HCP. High Impact Area five focuses on managing minor illnesses, reducing accidents and outlines how health visitors provide evidence-based safety advice to parents, including through child health clinics, baby groups and other parenting activities. PHE has worked with the RoSPA and CAPT to publish a report on reducing unintentional injuries in and around the home among children in 2018. This highlighted the most prevalent causes of unintentional injury hospital admissions and preventable death and serious long-term harm, including strangulation, and made recommendations around accident prevention at the local level. Moving forward, PHE has outlined an aim to reduce preventable accidents as part of the national priority on Best Start in Life (2020-2025). It aims to achieve this through the modernisation of the Healthy Child Programme which is taking place between 2020-2023. Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information. Yours sincerely, Professor Stephen Powis National Medical Director
Royal College of Nursing
20 Cavendish Square
London
W1G 0RN
Dame Donna Kinnair
Chief Executive & General Secretary
Telephone 020 7647 3781
Email
Executive Assistant:
Telephone
Email
20 April 2020
Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
Via email:
Dear Mr Hassell
Re: Regulation 28 Prevention of Future Deaths report - Rifky Grossberger (died
05.08.19)
This letter is in response to your request to Regulation 28: Prevention of Future
Deaths report that was received by the Royal College of Nursing on March16th
2020. I am sorry to hear about the tragic circumstances relating to the death of Rifky
Grossberger.
Your report states that ‘ … the midwives and district nurses who look after new
mums and their babies are well placed to offer advice, but may need a reminder to
warn of this particular danger.’ In preparing this response, we have consulted with
our members that span our range of Children and Young People Forums, and our
Professional Leads for Public Health, Midwifery, Children & Young People and
Primary Care.
Midwives and Health Visitors routinely provide new parents with written information
about a range of issues, including safety in the home. Discussions around safety is
an integral part of the national Healthy Child Programme of contacts with the family,
that is undertaken by the Health Visitor throughout the child’s early years.
The Healthy Child Programme for the early life stages focuses on a universal
preventative service, providing families with a programme of screening,
immunisation, health and development reviews, supplemented by advice around
health, wellbeing and parenting. The safety aspects of discussions with parents
includes the potential risk of strangulation and suffocation, with Health Visitors
highlighting and providing resources from the Child Accident Prevention Trusti and
NHS online advice for new parentsii.
In considering your report, we have reviewed and strengthened our guidance about
the potential risks of strangulation and suffocation on our clinical webpages for
Health Visitors, Midwives, School Nurses, Children’s Nurses, Neonatal Nurses and
General Practice Nurses. Further to this, we have also brought this matter to the
attention of our members through Forums and their social media platforms.
I trust that our response gives some assurance that safety advice is an integral part
of the Healthy Child Programme, and highlights the steps that the Royal College of
Nursing has taken to bring this issue to the attention of our members who provide
care to babies, children and their families.
Yours sincerely
Dame Donna Kinnair
Chief Executive & General Secretary
i https://www.capt.org.uk/strangulation
ii https://www.nhs.uk/conditions/pregnancy-and-baby/baby-safety-tips/
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