Bethan Harris

Chief Executive 
St. George’s Healthcare NHS Trust 
Blackshaw Road  
London SW17 0QT 

H.M. Assistant Coroner Dr Sean Cummings 
For the Coroner Area of West London   
West London Coroner’s Court 
Bagleys Lane 
Fulham  
SW6 2QA 

18 August 2020 

Dear Dr Cummings 

I  am  writing  in response  to  the  Regulation  28  Report that  you  issued to  St.  George’s  University 
Hospitals  NHS  Foundation  Trust  on  22  June  2020  following  the  Inquest  into  the  death  of  baby 
Bethan Naomi Harris which took place on 18 and 19 November 2019.  

I note your concerns as set out at paragraph 5 of the report.  For ease of reference, I will address 
the concerns in the order raised in the report.  

1  The  Inquest  was  held  one  year  after  Bethan’s  death.  During  the  course  of  the  oral 
evidence it emerged that several important learning issues had not been addressed.  

I am very sorry that the important learning issues and improvement actions related to each of 
the  issues  were  not  conveyed  effectively  during the  oral  evidence given  by  the midwives  at 
the  Inquest.  The  staff  involved  were,  and  still  are,  profoundly  affected  by  this  incident.  The 
Midwives  involved  had  not  participated  in  an  Inquest  hearing  before  and  found  it  incredibly 
stressful. I believe this impeded their ability to verbalise how deeply they were affected by the 
case  and  to  describe  their  reflection  and  learning  at  various  points  in  time  in  the  year 
following  Bethan’s  death.  I  am  aware  that  this  individual  reflection  and  learning  continued 
after  the  hearing  with  the  support  from  the  Professional  Midwifery  Advocate  (PAM)  team 
through  verbal  discussion,  written  reflection  and  a  Professional  Practice  Action  Group 
programme for one of the midwives. 

The  senior  midwifery  team  has  also  assured  me  that  all  of  the  highlighted  issues  in  the 
serious  incident  investigation  report  have  been  completed,  and  are  monitored  by  the 
maternity  governance  team.  In  response  to  the  serious  incident  action  point  1  ‘to  ensure 
patients are adequately counselled regarding management options in the post-dates period’ 

 
 
 
 
 
 
 
 
 
 
 
 
 the  maternity  governance  team  undertakes  a  quarterly  maternity  notes  audit.  This  involves 
auditing  the  notes of  women  attending for 40  and  41  weeks  antenatal  appointment  and  the 
information  given  regarding  induction  of  labour.  The  last  quarterly  audit  reported  67%  of 
women  had  induction  of  labour  discussed  and  offered  at  40  weeks  and  83%  at  41  weeks 
gestation. Although this percentage is below the expected  performance target of 95%  at 40 
weeks,  the  maternity  governance  team  is  working  towards  ensuring  induction  of  labour 
information is discussed and given from 36 weeks gestation in preparation for more in-depth 
discussions on induction of labour at 40 weeks. This audit will be repeated in October 2020 
and will review the notes of attendees at appointments between July to September 2020.  

Action point 2 of the serious incident report required  ‘greater clarity of options around risks, 
benefits and alternatives to induction of labour’. The induction of labour information leaflet has 
been reviewed and updated and is now available on the maternity page of the Trust website. 
As a Trust we recognise for many of our women English is a second language and we are in 
the  process  of  having  this  leaflet  translated  into  different  languages  which  will  be  available 
from 1 September 2020. 

The maternity governance team will continue to monitor this compliance with the provision of 
information,  discussion  and  offer  of  induction  of  labour.  The  team  is  also  responsible  for 
continuing  the  quarterly  audits  of  the  antenatal  care  pathway,  the  results  of  which  will  be 
shared  with  all  staff  at  various  forums  which  include  governance  meetings  and  the 
governance newsletter.  

2  There  were  issues  relating  to  handover  of  patients  to  midwives  and  at  the  time  of 
Inquest  there  had  been  no  further  specific training  in  relation  to  handover.    Indeed  it 
was  stated  that  the  process  in  place  at  the  time  of  Bethan’s  delivery  still  pertained 
without alteration.  This represented a risk to patients.   

Following on from the Inquest the maternity governance team undertook an audit of the use 
of  the  clinical  handover  tool  Situation  Background  Assessment  Recommendation  (SBAR) 
within the maternity unit. The result demonstrated poor compliance with the SBAR tool. The 
staff reported they were unclear on when and how to use the SBAR tool. This resulted in a 
review and update of how the SBAR tool is taught and used. The revised SBAR tool provides 
clarity on how, when and where the SBAR should be used; practical use of the tool has also 
been  incorporated  into  the  unit  mandatory  multi-disciplinary  training  which  includes  clinical 
scenarios. The updated version of the SBAR tool is included in the maternity unit Admission 
Guidelines.  The  updated  version  of  the  SBAR  tool  was  re-launched  in  May  2020  through 
various forums including staff meetings, face to face teachings, newsletter and email.  

The maternity governance team is responsible for undertaking quarterly audits of the SBAR 
tool  and  sharing  the  results  both  locally  within  the  maternity  unit  as  well  as  at  the  Trust 
monthly divisional and directorate meetings.  

3  At the time of Inquest a team debrief, which you consider to be a source of learning to 

reduce the risk of serious incident in future, was still outstanding. 

Although there had not been a formal team debrief, there had been numerous meetings with 
individual members of staff and groups of two or three staff on a number of occasions, long 
 on 16 November 
before the inquest, to discuss and reflect on the care provided to Ms 

 
 
 
 
 2018.  Following  the  coroner’s  Inquest,  a  team  debrief  was  facilitated  by  the  Professional 
Midwifery  Advocate  (PMA)  team  and  lead  midwife  for  governance  with  attendance  and 
support  from  the  legal  team.  The  midwives  in  this  case  have  attended  leadership  and 
PROMPT (Practical Obstetric Multi-Professional Training). The Trust recognises the value of 
this training and registered all staff groups to attend PROMPT.  

Prior to the Covid-19 pandemic more than 90% of staff within the maternity unit had attended 
PROMPT  training.  The  pandemic  resulted  in  a  pause  on  training.    However,  following  the 
easing of restrictions, the maternity practice support team is now working towards achieving 
the  target  of  100%  staff  trained.  Compliance  with  mandatory  training  is  monitored  by  the 
maternity governance team. 

The arranged Human Factors training has, unfortunately, been suspended due to the Covid-
19  pandemic  but  once  it  restarts,  it  will  equip  all  midwives  to  develop  better  situational 
awareness.  Due  to  the  requirements  of  social  distancing  we  are  currently  working  with  the 
training provider to explore alternative methods for the delivery of the training.  

The  value  of  team  debriefs  following  any  serious  incident  has  been  acknowledged  by  the 
midwifery governance team. The team  agrees wholeheartedly that staff should be offered a 
team debrief immediately following any serious or adverse incidents and have facilitated team 
debriefs since January 2020.  

4  There  was  little  evidence  from  the  oral  evidence  given  that  any  effective  reflection, 
reflective  discussions  or  learning  had  taken  place  subsequent  to  Bethan’s  birth  and 
then death.  You consider it important that organisations seek to ensure individual and 
collective reflection to seek to avoid repetition. You felt that the evidence for this, one 
year on, was lacking. 

Learning from  Bethan’s death  has  been shared throughout the maternity unit  via  PROMPT, 
as outlined above. The case, appropriately anonymised, was presented at the maternity unit 
meeting  on  15  November  2019  and  at  the  Clinical  Governance  study  day  on  19  December 
2019.  Individual  reflection  and  learning  has  also  taken  place  with  the  support  of  the  PMA 
team through verbal discussion and written reflection.  

The issues identified have been communicated to staff via the governance newsletter and at 
staff forums. There is also on-going learning through mandatory training as Bethan’s case is 
used  as  a  reference  during  the  Fetal  Monitoring  and  Skills  and  Drills  study  day.  It  is  a 
requirement at the Trust that each member of staff attends a yearly training update with the 
practice development team facilitating monthly training sessions. As of February 2020 more 
than 90% of the midwives and doctors have attended this training. 

I  am  aware  from  the  senior  midwifery  team  who  have  reported  back  to  me  that  there  has 
been,  as  reflected  in  the  paragraphs  above,  many  individual  discussions  with  the  midwives 
involved about the events of Bethan’s birth and subsequent sad death in November 2019, but 
there was no  recognised structure to support  a  formal  team  debrief  involving  all  staff  in  the 
year  following  Bethan’s  death.  The  team,  and  the  organisation  as  a  whole,  unequivocally 
accept  that  individual  and  collective  reflection  after  such  incidents  is  key  to  avoiding 
repetition, and it is truly regrettable that this was not taken forward in a clear and structured 
manner  in Bethan’s  case.   We hope  you  will  accept  that this  has  now  been  addressed and 
will always feature in the way such incidents are managed in future.  

 I  hope  this  response  provides  assurance  that  the  Trust  is  fully  committed  to  learning  from 
incidents  and  it  is  a  matter  of  true  regret  for  all  involved  that  this  was  not  demonstrated 
effectively in Bethan’s case.   

Please do not hesitate to contact me if you would like further information or assurance on any 
residual concerns you may have.   

Yours sincerely  

Chief Operating Officer  

On behalf of 

Chief Executive 

C.C Ms