Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0111, written 12 May 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 May 2020 |
|---|---|
| Reference | 2020-0111 |
| Deceased | Harrison Hassall |
| Coroner | Professor Catherine Mason |
| Coroner area | Leicester City and South Leicestershire |
| Category | Community health care · Child Death (from 2015) |
| Organisation named | University Hospitals of Leicester NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This from is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 Department of Health and Social Care 1 CORONER I am Professor CE MASON, Senior Coroner for the area of Leicester City and South Leicestershire 2 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. 3 INVESTIGATION and INQUEST On Ninth April 2019 I commenced an investigation into the death of Harrison Colin Hassall aged 2 Days. The investigation concluded at the end of the inquest on Ninth March 2020. The conclusion of the inquest was: Natural causes The cause of death was established as: I a Hypoxic ischaemic encephalopathy I b Delayed delivering I c II 4 CIRCUMSTANCES OF THE DEATH Harrison Hassall was born pre-term and breech at the Leicester Royal Infirmary on 12th January 2019 following delayed delivering contributed to by the failings of healthcare professionals upon whom he was dependent. As a result, he sustained brain damage and died peacefully on 14th January 2019 at the hospital with his parents and family present. 5 CORONER’S CONCERNS The MATTERS OF CONCERNS are as follows: It was highlighted in evidence that midwives may be permitted to work in the community too soon after qualifying and therefore may not have enough experience. The University Hospital of Leicester NHS Trust have indicated that they will be reviewing the appropriate Grade that a midwife should have attained before taking up a community post. This is not a matter that is relevant to only Leicester. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) 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 8th July 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 Chief Coroner and to the following Interested Persons: (Mother) (Father) University Hospitals of Leicester NHS Trust, East Midlands Ambulance Service 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 coroner, at the time of your response about the release or the publication of your response by the Chief Coroner. 9 Professor Catherine E. Mason H.M. Senior Coroner Leicester City & South Leicestershire Honorary Professor East Midlands Forensic Pathology Unit (Leicester Cancer Research Unit) Tel: 0116 454 1030 Dated: 12 May 2020
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.
From Nadine Dorries MP Minister of State for Patient Safety, Suicide Prevention and Mental Health 39 Victoria Street London SW1H0EU 020 7210 4850 • Department of Health & Social Care Your Ref: CEM/00617-2019 Our Ref: PFD-1236272 Professor Catherine E Mason HM Senior Coroner, Leicester City and South Leicestershire HM Coroner's Office Town Hall Town Hall Square Leicester LE1 98G Thank you for your letter of 12 May 2020 to Matt Hancock, received by the Department on 26 June 2020, about the death of Harrison Colin Hassall. I am responding as Minister with portfolio responsibility for maternity services and patient safety. Let me start by saying how deeply saddened I am to learn of the tragic circumstances surrounding the death of baby Harrison. I offer my most heartfelt condolences to Harrison's parents and all those affected by Harrison's death. That Harrison's death was contributed to by the failings of healthcare professionals, as your investigation has concluded, must be particularly distressing and we must do all we can to learn from those failings to prevent future tragedies. I am advised that investigations conducted by the University Hospitals of Leicester NHS Trust and the East Midlands Ambulance Service NHS Trust into the care provided to Harrison and his mother identified areas for improvement that resulted in recommendations for action. I am further advised that those actions have been implemented and the learning from this incident has been shared widely to support improvements in safety and in particular, the response of multi-disciplinary teams to maternity emergencies. I encourage the NHS organisations involved to reflect fully on the findings of the coronial investigation and to consider if there is more that can be done to learn from the circumstances of Harrison's death. Your report explains that evidence heard at inquest suggested that midwives are permitted to work in the community too soon after qualification and without adequate experience. In considering those concerns, my officials have taken advice from NHS England and NHS Improvement (NHSEI) and the Chief Midwifery Officer, Professor Jacqueline Dunkley-Bent . OBE, and I can provide the following information in relation to the education and training, ongoing professional development and supervision of midwives, including community midwives, in England.
See every Prevention of Future Deaths report matching University Hospitals of Leicester NHS Trust, 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.