Theo Young

Headquarters 
East Surrey Hospital 
Canada Avenue 
Redhill 
RH1 5RH 

Tel: 01737 768511 
www.sash.nhs.uk 

8th July 2020 

Please reply to: 
Name:  Michael Wilson  
Title:   Chief Executive 
   :     01737 
Email:   

@nhs.net  

By email to: 
Dr Karen Henderson 
HM Assistant Coroner for Surrey 
Dr Karen Henderson HM Assistant Coroner for Surrey 
Station Approach 
Woking 
GU22 7AP 

Dear Dr Henderson, 

Response to Regulation 28 Report – The Inquest Touching the Death of Theo 
Benjamin Young on 29.05.2018 from Surrey & Sussex Healthcare NHS Trust 

The Trust has received the Regulation 28 Report following the Inquest Touching the 
Death of Theo Benjamin Young.  In this report you rightfully detailed eight failures in the 
care we provided to Theo and his mother during her labour for which we are truly sorry. 
We respectfully note that in the report you reported no matters of concern pertaining to 
the Trust and we also note that in the Inquest you concluded that you had heard 
considerable evidence on actions already taken by the Trust regarding preventing future 
deaths. You were satisfied that the Trust took this extremely seriously and commended 
the Trust for having independently taken steps to change practice following Theo’s 
death.  

In order to assure all stakeholders, the Trust sets out here the specific actions that have 
been taken to minimise the risk of similar failings happening in the future: 

In recognition of the effect staffing ratios and skill mix have on safety, we have 
increased midwifery staffing numbers by 10 full time equivalents and undertake a six 
monthly Board level review of midwifery staffing. We have instituted a daily review of 
staff allocation throughout the maternity department by the delivery suite co-ordinator 
and manager on call to ensure safe allocation and redeployment of staff. 

In recognition of the failings regarding CTG monitoring and interpretation we have 
completed the following: 

An Associated University Hospital of 
Brighton and Sussex Medical School 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 All staff involved in the care of women in the maternity department complete a CTG 
online training package and an annual competency assessment.  All new starters will 
complete this before caring for women in labour and all staff will repeat this training and 
competency assessment on an annual basis. We have reviewed the ‘fresh eyes’ 
approach to review fetal and maternal observations during labour so that independent 
review of CTG traces is a routine part of care. All staff are clear that if a satisfactory 
CTG trace cannot be obtained then fetal scalp electrodes are to be used and if this 
proves not possible then immediate escalation to the senior obstetric team is expected. 
The Trust has also recruited a Senior Lead Midwife whose role is to ensure daily 
monitoring and oversight of care on the labour ward. 

Since these actions were put in place, our Maternity Department was inspected by the 
Care Quality Commission and in January 2019 was rated ‘Outstanding’. The 
department has also been awarded compliance with the Maternity CNST incentive 
scheme last year which includes the provision of assurance in regard to the Saving 
Babies Lives Care Bundle   

In the Regulation 28 Report you raised specific concerns regarding the role of HSIB in 
their conduct, investigation and conclusion. We agree that the requirement of HSIB not 
to undertake our own investigation could have prevented the timely undertaking of 
remedial action. In fact, as we have described, the Trust did formulate and complete an 
action plan long before the HSIB report was finalised. If we had not done this and 
instead waited for more than a year for the final report then potentially more babies 
could have been at risk. Our concern would be the potential response of other 
organisations to a request like this from HSIB. In addition, the request from HSIB for the 
Trust not to collect statements from the staff involved in the incident seems wrong in our 
view. It is self-evident that compiling contemporaneous records of what happened will 
be more accurate than relying on individual memories of the incident some months 
later. 

The Trust acknowledges that the timeline of HSIB investigations has improved since 
their investigation into the death of Theo Benjamin Young. 

Safety of our patients remains the Trust’s paramount focus and being open, honest and 
transparent are crucial factors in being an organisation that learns from incidents. We 
have shared this response with NHS England and the Care Quality Commission. 

Yours sincerely 

Michael Wilson CBE 
Chief Executive  

An Associated University Hospital of 
Brighton and Sussex Medical School

From Nadine Dorries MP 
Minister of State for Patient Safety, 
Suicide Prevention and Mental Health 

39 Victoria Street 
London 
SW1H 0EU 

020 7210 4850 

21 May 2020 

Our Ref: PFD-1217773 

Dr Karen Henderson 
HM Assistant Coroner, Surrey 
HM Coroner's Court 
Station Approach 
Woking GU22 7AP 

Dear Dr Henderson 

Thank you for your letter of 20 April 2020 to Matt Hancock about the death of Theo 
Benjamin Young.  I am replying as Minister with responsibility for patient safety and 
maternity.  

Firstly, I would like to say how deeply sorry I am for the tragic death of baby Theo and for 
the failings in care detailed in your report.  That Theo’s death could have been avoided is 
extremely distressing and I offer my most heartfelt condolences to his parents and all 
those affected by his death. I am determined that we do all we can to learn from Theo’s 
death to ensure the safety of health services and prevent such deaths from occurring 
again. 

Your report raises important matters of concern in relation to the conduct by the 
Healthcare Safety Investigation Branch (HSIB) of investigations under its Maternity 
Investigation Programme, and specifically the investigation carried out into Theo’s death.   

It may be helpful if I explain that HSIB was established in April 2017 to conduct 
independent investigations of serious patient safety incidents in NHS-funded care across 
England, with a specific focus on system-wide learning and improvement.  In 2018, HSIB‘s 
remit expanded to include the investigation of maternity incidents under qualifying criteria 
set out in legislation1.  

HSIB has dual accountability.  HSIB reports to NHS England and NHS Improvement 
(NHSEI) on operational issues and to the Department of Health and Social Care on 
performance.  Quarterly accountability meetings, that I chair bi-annually, monitor progress 
and review performance against agreed key performance indicators for HSIB’s national 
and maternity investigation programmes.   

1 
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/702938/NHS_Trust_D
evelopment_Authority__HSIB__Directions_2018.pdf 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                                                           
 
 In relation to HSIB’s important work on the Maternity Investigation Programme, I am aware 
that investigation processes, such as obtaining family approval and accessing medical 
records, have affected the overall timescales, causing a backlog of reports.  However, 
HSIB is taking measures to improve performance, including the adaptation of some 
investigation processes and additional support from clinical advisors and I am advised the 
backlog is reducing.    

My officials, together with NHSEI, have considered the concerns in your report carefully 
and assurance has been sought from HSIB of the processes in place for maternity 
investigations, as well as its conduct of the investigation into the death of Theo Young.  

I agree with you that it is vitally important that learnings are identified and shared as 
quickly as possible.  As HSIB has explained in its response to your report, it recognises 
the vital importance of rapid learning, with opportunities within the investigation process for 
Trusts to identify and address immediate safety risks.  For example:  

•  NHS trusts are advised to complete rapid 72-hour reviews to enable the 

identification and mitigation of immediate safety risks;  

•  HSIB investigators escalate immediate safety risks where they are identified to 
senior Trust management and seek assurance that they are addressed; and, 

•  HSIB investigators provide regular written updates on investigations to Heads of 

Midwifery.  In addition, roundtable reviews and quarterly thematic reviews are held 
with Trusts that have active HSIB investigations to share learning from HSIB’s wider 
Maternity Investigation Programme.  

HSIB advises that its investigation into Theo’s death provided the Surrey and Sussex 
Healthcare NHS Trust with opportunities to identify and address immediate safety risks in 
its maternity services.  

You may also wish to note that NHS Trusts are expected to identify learnings in cases of 
stillbirth or neonatal death through use of the National Perinatal Mortality Review Tool.   

As accepted by HSIB, the length of time it took to conclude the investigation into Theo 
Young’s death exceeded the expected timeframe.  I note that this was one of the first 
investigations conducted by HSIB under its Maternity Investigation Programme.  Since 
then, HSIB has made changes to its investigation methodology and processes to enable 
them to share early learning with Trusts.  

HSIB has also confirmed that, through ongoing communication with the Trust, it provided 
opportunities for safety information to be shared and acted upon as the investigation into 
Theo’s death progressed.  

In relation to the quality of the investigation by HSIB of Theo’s death, HSIB advises that 
this was conducted in line with the statutory Directions and disputes that inaccuracies were 
due to error on its part.      

 
 
 
 
 
 
 
   
 
 
 
 
 
 I am advised that HSIB’s investigation into the death of Theo Young made six 
recommendations to the Surrey and Sussex Healthcare NHS Trust and I expect the Trust 
to take the necessary action to ensure these are addressed, as well as reflect on the 
findings of your investigation.   

Finally, I wish to take the opportunity to emphasise the important work underway nationally 
to improve the safety of maternity services.  

The Government’s Maternity Ambition is to halve the 2010 rate of stillbirths, neonatal and 
maternal deaths and brain injuries in babies occurring during or soon after birth by 2025.  
The ambition also includes reducing the rate of pre-terms births from eight to six per cent.   
The NHS Long-Term Plan includes new measures to improve safety, quality and continuity 
of care that will help achieve our Maternity Ambition.  This includes every maternity service 
in the NHS in England actively implementing elements of the Saving Babies’ Lives Care 
Bundle which comprises key aspects of care such as, reducing smoking in pregnancy; risk 
assessment and surveillance for fetal growth restriction; raising awareness of reduced fetal 
movement; effective fetal monitoring during labour and reducing preterm birth. 

I hope this reply is helpful.  Thank you for bringing these concerns to my attention.  

NADINE DORRIES

22 May 2020 

Dr Karen Henderson  
HM Assistant Coroner for Surrey 
Station Approach  
Woking  
Surrey GU22 7AP 

Dear Dr Henderson, 

HEALTHCARE SAFETY INVESTIGATION BRANCH 

HSIB, A1 

Cody Technology Park 

Farnborough 

Hampshire 
GU14 0LX

RE: Matters of Concern regarding HSIB in The Inquest Touching the Death of Theo 
Benjamin Young: A Regulation 28 Report – Action to Prevent Future Deaths 

Thank you for your report The Inquest Touching the Death of Theo Benjamin Young: A 
Regulation 28 Report – Action to Prevent Future Deaths which I received from your office by 
email on 20 April.  

Within it you have raised several Matters of Concern pertaining to the Healthcare Safety 
Investigation Branch (HSIB), requesting that we provide a response to you that contains 
details of action taken or proposed to be taken, setting out the timetable for such action, or 
explanation of why no action is proposed. 

I appreciate the opportunity for HSIB to respond to your concerns and explain our processes 
for addressing safety risks identified during HSIB maternity investigations, both in general 
and with respect to our investigation into the neonatal death of baby Theo. We have 
thoroughly reviewed all our records and evidence collected by our investigation team during 
the investigation, providing a comprehensive explanation and clarification for each of the 
three concerns you have raised.  

Matter of Concern 1 

“The HSIB specifically requested the Trust not to undertake their own investigation 
effectively preventing the recognition of causes of concern and therefore being unable to 
undertake any immediate and necessary remedial action at the earliest opportunity to 
prevent future deaths”. 

HSIB response 

HSIB places utmost importance on the need to ensure that rapid learning takes place for 
cases that fall within the eligibility criteria of HSIB’s maternity investigation programme. 
There are several stages throughout HSIB investigations where the opportunity for 
identifying and addressing safety risks is provided to trusts, and these were implemented 
during the investigation of baby Theo’s death.  

1.

It is HSIB policy that all NHS trusts are advised to complete 72-hour reports for cases
that are referred as eligible for investigation. The purpose of this is to ensure that trusts
can readily identify immediate safety concerns and take necessary actions while they
await the commencement and outcome of HSIB’s more in-depth reviews. Trusts are not
mandated to share their 72-hour reports, but many share them with HSIB voluntarily.

 This enables HSIB to compare the Trust’s and our investigation’s early findings so that 
any areas for concern may be highlighted.  With respect to baby Theo’s investigation, the 
Surrey and Sussex Healthcare NHS Trust (‘SaSH Trust’) undertook a 72-hour review, 
but they declined to share this review with HSIB. Following ongoing engagement with the 
senior management team at SaSH Trust, they now share their 72-hour reports with HSIB 
on request.  

2.  To further support trusts with rapidly addressing safety risks in their maternity services, 

HSIB investigators also immediately escalate any safety concerns uncovered during the 
investigation process to the Head of Midwifery and Clinical Director. This case was 
discussed at our clinical panel at the outset of the investigation, which identified key lines 
of enquiry, but the panel did not identify any preliminary findings which suggested an 
immediate risk to patient safety. Through our regular engagement processes, we ensure 
that prompt actions are taken by trusts in response to any matters raised through early 
escalation. Fortnightly written updates are sent to all Trust Heads of Midwifery to provide 
updates on the progress of HSIB’s local investigations and to seek support with 
addressing any barriers to progress.  These fortnightly updates are specific to each local 
trust and detail the progress of all investigations relating to that trust.  

3.  HSIB held a roundtable review with SaSH Trust on 10 January 2019 which included a 

discussion of baby Theo’s case. A summary letter was sent to the Head of Midwifery on 
the same day and outlined HSIB’s concerns relating to staffing, escalation, interpretation 
services and debriefing. 

4.  Quarterly thematic reviews are also held with each trust where there are active 

investigations to share learning accruing from HSIB’s maternity investigations across the 
country, alongside identifying themes for each organisation where there are particular 
areas of concern. HSIB held quarterly review meetings with SaSH Trust on 10 May 
2019, 6 September 2019 and 6 December 2019.  

Through these processes, HSIB provided sufficient, appropriate and timely information to 
support SaSH Trust’s early learning activity from baby Theo’s death.  

In terms of the role of HSIB’s maternity investigations, the DHSC Safer Maternity Report 
2017 referenced HSIB maternity investigations, stating that, 

“These investigations will be the primary and, as far as possible, the only investigation of the 
individual case and may be informed if appropriate by tools that local providers will be using 
such as the Standardised Perinatal Mortality Review Tool for perinatal deaths. This will 
ensure consistency for all 'Each Baby Counts' cases nationally and avoid duplication and 
unnecessary complexity for families.” 

Matter of Concern 2 

“HSIB indicated to the Trust at the outset that their investigation would take approximately 
six months which is highly likely to delay the introduction of any immediate necessary 
measures by the Trust to prevent further deaths”.  

 
 
 
 
 
 
 
 
 
 HSIB response 

The timescale to produce HSIB reports is set in paragraph 4(1) of the HSIB Maternity Directions 20181 as 
follows: 

HSIB must, within a reasonable period of time, produce a report on the matters set out in sub-
paragraph 3(2) and, as far as reasonably practicable, such period should not exceed six months 
from the date on which the qualifying maternity case in question was referred to it 

The timeline in this particular case is set out below: 

25/05/18 
12/06/18 
9/10/18 
15/02/19 
28/02/19 
8/03/19 

08/03/19-17/05/19 

17/05/19 

28/06/19 

Incident date 
Referral date 
Draft report submitted for QA 
Date draft report shared with trust 
Trust response returned 
Shared with the family and amendments 
made 
Reviewed with family on three separate 
occasions, and shared with members of 
staff, further comments addressed 
Final Trust amendments received and 
actioned 
Final report completed and signed off 

This report did exceed our target timescale; however, HSIB communicated regularly with 
SaSH Trust and the family during the investigation process and provided the Trust with 
relevant safety information. This is a standard process in our investigations as detailed in the 
response above and enables trusts to introduce any immediately necessary measures to 
prevent future deaths before the sharing of our report.  

This was one of the first investigations of the HSIB Maternity Programme and many of the 
processes and systems had yet to mature. The HSIB has taken on board the feedback and 
is assured that the continuous development since this investigation has led to more rapid 
investigation times whilst maintaining the quality and communication with trusts and families.   

1 The National Health Service Trust Development Authority (Healthcare Safety Investigation Branch) 
(Additional Investigatory Functions in respect of Maternity Cases) 2018   

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Matter of Concern 3 

“The initial draft report contained factual errors and inaccuracies requiring considerable input 
by the Trust to resolve. The final report is insufficiently detailed and was completed 18 
months after the death, during which time further deaths could have resulted”. 

HSIB response 

HSIB consider that the report provides detailed reflection of the investigation that was 
undertaken. Evidence was collated from the medical records, Trust guidelines and policies 
and interviews with the family and staff (as outlined as requirements in paragraph 3 (3) of the 
HSIB Maternity Directions 2018). 

The final report established the facts, having reviewed the sequence of events and 
contributory factors that led to the outcome for this baby, taking into consideration specific 
concerns raised by the family. The final report had six safety recommendations which were 
aligned to current best practice. HSIB were able to make these recommendations based on 
the information provided during the investigation. 

HSIB’s quality assurance process involves sharing the draft investigation report with the 
Trust and family for their comment on factual accuracy. With regard to baby Theo’s death, 
SaSH Trust made seven references to content being ‘factually incorrect’. Following HSIB’s 
review of the investigation evidence, only two of SaSH Trust’s factual accuracy submissions 
were found to be correct and these were due to information not being made available by the 
Trust to the investigation team at the time.  

A draft version of the report was shared with SaSH Trust 8 months after referral. The Trust 
returned the draft 13 days later with suggested amendments. Between 08/03/19 and 
17/05/19 (10 weeks) the Trust continued to review the report and returned further 
amendments on 17/05/19. The final version of the HSIB investigation report was shared with 
the family and SaSH Trust 14 months after Theo’s death, not 18 months as stated. The 
ongoing communication processes between HSIB and the Trust during that time were 
designed to ensure that opportunities for identifying and addressing safety risks were not 
missed. Since this investigation, the HSIB are not aware of cases with similar themes 
repeated within this Trust. 

I trust this response provides you with explanations and assurance about HSIB’s 
investigation and report production processes, and our commitment to reducing patient 
safety risk in NHS maternity services.  

Your sincerely  

Chief Investigator 

PA to 

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