Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0143, written 16 Jul 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Jul 2020 |
|---|---|
| Reference | 2020-0143 |
| Deceased | Kobi Wright |
| Coroner | Jacqueline Lake |
| Coroner area | Norfolk |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Child Death (from 2015) |
| 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: REPORT TO PREVENT FUTURE DEATHS . REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: Dr c/o RadcliffesLeBrasseur Ref: WRC/KMD/900500.4069 85 Fleet Street London EC4Y 1AE 1. CORONER I am Jacqueline LAKE, Senior Coroner for the area of Norfolk 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 14/08/2019 I commenced an investigation into the death of Kobi David WRIGHT aged Less than 1 day. The investigation concluded at the end of the inquest on 9 July 2020. The medical cause of death was: 1a) 1b) 1c) 2 Preterm Stillbirth Complicated Instrumental and Caesarean Delivery - Prematurity The conclusion of the inquest was: Stillbirth. 4. CIRCUMSTANCES OF THE DEATH Maternal membranes ruptured on 1 March 2019 and there was admission to James Paget University Hospital where monitoring was undertaken. On 3 March 2019 examination and reassessment took place. Following an examination at 13:30 and again at 13:50, forceps delivery was attempted. Kobi’s head was delivered vaginally but delivery of his body was unsuccessful. An attempt was made to deliver Kobi by caesarean section which was initially unsuccessful, and delivery by forceps re- attempted. This was not successful and delivery by caesarean section was again attempted. Kobi was eventually delivered at 15:28 hours. He showed no signs of life and after attempts at resuscitation and assessment Kobi was declared dead. 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: 1. D evidence was that the cervix was almost fully dilated at 12:30 and 13:50 examinations at which point it could be “pushed easily”, which was not supported by midwife’s evidence of examination at 13:30 (8cm) nor of what transpired at attempted delivery, namely that cervix “retracted” to 6 to 7cm; 2. Dr evidence was that during a telephone conversation at 13:57 he did not express concern about the CTG reading and did not give this as the reason to proceed to delivery of Kobi. This was in conflict to the evidence of Dr Consultant Obstetrician/Gynaecologist and to his first statement 16.7.2018 para 6. 3. Dr evidence at the inquest that he expressed concern about Kobi’s mother being pre- term, high risk with prolonged rupture of membranes was not contained in his first statement nor in his record of the conversation. In any event the evidence of Ms who gave evidence was that these would not be reasons in themselves to proceed to an early delivery at that time. and the expert Mr 4. Further second statement 21.4.2020, refers to some consideration being given to variable decelerations and variabilities contained in the CTG trace when making his decision to proceed to delivery at that time. It was accepted by Dr consultant and Mr Ms expert, that the CTG readings were within normal range and would not be a reason to proceed to delivery at that time. Their evidence was it would be appropriate in light of the full clinical picture and the CTG readings to “wait and see” how matters progressed. 5. Dr gave evidence that his arranging to take Kobi’s mother to theatre and prepare for delivery, and then carrying out a further vaginal examination at that time, would stand in for a later examination to see how matters were progressing. This was not regarded as good practice by the expert on the basis, it would be better to carry out a further examination after an hour, and then decide how to proceed with the delivery. 6. Dr did not accept the Consultant’s offer of assistance but regarded himself as fully competent to carry out the procedure. 7. Dr proceeded with a forceps delivery of the baby’s head. The body did not follow and the had not encountered before. Nor had Mr the expert cut the cervix and rotated the head and tried unsuccessfully to deliver the expert said in evidence the baby’s head on its own cervix “retracted” (which Dr witness). Dr shoulders through the incision. Mr should never be rotated due to the damage this can cause. instructed a midwife to replace the baby’s head. then attempted to deliver the baby via caesarean section, which was unsuccessful. then attended and arranged for the Paediatric Team to be called. She was eventually 8. Dr 9. Dr 10. Ms able to deliver the baby 11. There was a conflict in the evidence as to whether Ms applied both forceps blades. The evidence of Ms was preferred in that she was the one performing the procedure and would be best placed to know what she was doing and she had throughout been a good and competent witness. 12. There was no evidence that Dr had undergone training in emergency obstetrics in the recent period prior 3 March 2019. Dr instigation of North Devon District Hospital. has undergone training since 3 March 2019 but at the 6. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe 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 09 September 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: Chief Executive, James Paget University Hospital parents via Morgan Jones & Pett, Solicitors I have also sent it to Ethical Guidance Department, General Medical Council, Regents Place, 350 Euston Road, London NW1 3JN The Chief Executive, North Devon District Hospital, Raleigh Heights, Barnstaple EX31 4JB Department of Health Care Quality Commission Healthcare Safety Investigation Branch (HSIB) Healthwatch Norfolk Child Death Overview Panel who may find it useful or of interest. 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. Dated: 16 July 2020 Jacqueline LAKE Senior Coroner for Norfolk Norfolk Coroner Service Carrow House 301 King Street Norwich NR1 2TN
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.
r1'1:;1 James Paget University Hospitals NHS Foundation Trust Lowestoft Road Gorleston Great Yarmouth Norfolk NR31 6LA Main Switchboard: 01493 452452 Direct Dial: Direct Fax: E mail: complaints@jpaget.nhs.uk www.jpaget.nhs.uk 26 August 2020 2BAUG 2020 Ms Jacqueline Lake LL.M Senior Coroner for Norfolk Carrow House 301 King Street Norwich NR1 2TN Dear Ms Lake Re: Regulation 28 Report to Prevent Future Deaths following the inquest into the death of Kobi David Wright. T~ank you for your letter dated 16 July 2020 following your inquest into the death of Kobi David Wright. Firstly, I would like to reiterate my condolences on behalf of the Trust to Kobi's family for his sad passing. Following the evidence heard at your inquest, the medical cause of death was given as: 1a) Pre term Stillbirth 1 b) Complicated Instrumental and Caesarean Delivery 1c) - 2) Prematurity 1.understand that you have made 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. The Trust has carefully considered the issues set out in your letter ih order to respond to your concerns. The Trust 'is continuing to take steps to recruit substantive doctors as first preference. Unfortunately, it is not always possible to employ only substantive staff, and to ensure safe staffing levels are maintained across the services, it is at times necessary to employ locum doctors. The Trust's Executive Lead for Workforce is currently reviewing the recruitment process fo ensure that suitably trained -and experienced doctors are comprehensively inducted at the hospital. This review will be concluded and the changes implemented by the end of September 2020. At present, the i;nedical staffing team request information from framework agencies to ensure the Trust has all compliant information before employment of any doctor is agreed. This information includes a copy of the CV, two current references, GMC and DBS checks, and Occupational Health (OH) records which are also r~viewed with the Trust's OH provider. A copy of the individual's mandatory training log is provided by the agency: the agency's Responsible Officer will e·nsure that training is up to date. The CVs, training certificates and references are approved by the speciality's consultant body before employment to ensure they are safe to fulfil the vacancy. Following your inquest, the reviewing consultant will, in writing, respond to the staffing team confirming they are satisfied that the clinician meets their requirements. This confirmation will include the date and time the documentation was verified. Additionally, the Trust has started to work with the clinical leads to devise c;1 detailed person specification of all essential and desirable qualities for each speciality. This specification will be shared with the agency, with the expectation that only clinicians that meet these criteria will be nominated for employment. In a situation where a locum doctor is required at short notice, and they do not meet all essential criteria, the staffing team will carry out a risk assessment, with the clinical team, to decide whether the clinician can be employed. This risk assessment will consider any mitigating factors, for example if they are named on the specialist register. If it is appropriate for the clinician to work at the Trust, the risk assessment will be signed by the clinical lead or th_eir deputy and shared with the supervising clinician. On day one at the Trust, locum doctors attend mandatory training and engage in a supervisory period in their department to ensure they are orientated. During this period, the clinician will work alongside a substantive staff member to familiarise themselves with local practice and ensure they have the appropriate skills required for their employed position. This staff member will be responsible for observing experience and skills during this period, and will raise any concerns to the appropriate clinical lead for action. If a locum doctor is unable to participate in a supervisory period, this will also be risk assessed by the staffing team before working. After a period of frequent employment, the Trust's current practice is to offer a substantive contract to the clinici.an. The Trust supports its permanent staff to continue with their professional development and offer training courses and study leave to aid this. This helps increase the pool of substantive doctors at the Trust providing consistency within the services. The Trust works hard to maintain an open culture and encourages staff to raise concerns to appropriate manag·ement; this includes any capability issues. The hospital is focussed on patient safety and promptly investigates any concerns regarding a clinician's competence. The Trust's Medical Director actively considers whether steps outside of the hospital's local · policy is required and if referrals to the GMC are required. I would like to thank you for bringing your concerns to my attention. If you require anything further, then ·please do not hesitate to contact me. I understand that this letter may be shared witt, Kobi's family and I would like to take this · opportunity to again personally extend my sincere condolences for their loss. Yours sincerely Chief Executive
By Email
STRICTLY PRIVATE & CONFIDENTIAL
Jacqueline Lake
Senior Coroner for Norfolk
Norfolk Coroner Service
Sent by Email Only
7th Floor, 85 Fleet Street
London
EC4Y 1AE
www.rlb-law.com
Direct Dial +44 (0)20 7227 6746
Tel +44 (0)20 7222 7040
Fax +44 (0)20 7222 6208
LDE 113 London Chancery Lane
info@rlb-law.com
9 September 2020
Our Ref: BM/BM/900500.4069
Your Ref:
23239827v1
Dear Madam
MDDUS: Dr
Regulation 28 Report to Prevent Future Deaths
Inquest touching on the death of Baby KW
We write further to receipt of the Regulation 28 report addressed and for the attention of Dr
following the inquest heard before you between 7 – 9 July 2020 touching on the death of Kobi David Wright.
From the outset we confirm that very shortly after the inquest (and before the Regulation 28 report was
referred himself to the General Medical Council in view of the inquest outcome. The
received) Dr
is engaging with.
Council have opened an investigation which Dr
in response to the concerns
Nevertheless, we enclose for your consideration a document from Dr
has spoken with his colleagues at the North Devon District
that are highlighted in your report. Dr
Hospital and has been proactive in his efforts to improve his knowledge and partake in training for obstetric
emergencies.
In particular, we would highlight that Dr
, in addition to having completed the K2 Training Program,
which includes a competency assessment tool, has made preparations to attend PROMPT training (Practical
Obstetric Multi-Professional Training) when it resumes. This has included him purchasing a copy of the
PROMPT training manual which he is reviewing ahead of the course. However, while awaiting that training,
is also re-reviewing the K2 courses that he completed prior to the inquest, but this time with the
Dr
inquest findings in mind. Dr
s reflections confirm that he has two simulator sessions outstanding to
be undertaken in relation to the assessment of CTGs before he will again have completed this training. The
in simulated ‘live atmosphere’ scenarios to make decisions in
simulator sessions will challenge Dr
anticipates completing these simulator sessions in the next few
respect of CTG management. Dr
weeks.
Unfortunately, the availability of training courses to attend in person are limited as a result of the global
, the Labour Ward
Covid-19 pandemic. However, Dr
Lead at the North Devon District Hospital. We enclose a letter from Mrs
which confirms that she
holds a number of positions, including Risk Management Lead, College Tutor and Training Programme
Director South West Peninsula. We therefore suggest she is very well placed to assess Dr
and
comment upon his practice, having been approach by him proactively seeking obstetric emergency training.
has attended two sessions with Mrs
RadcliffesLeBrasseur LLP is authorised and regulated by the Solicitor's Regulation Authority (SRA number
668181) and is a limited liability partnership, registered in England and Wales (registration number
OC428287) having its registered office at 7th Floor, 85 Fleet Street, London, EC4Y 1AE, where a list of
Members of the LLP may be inspected. We use the word 'partner' to refer to a Member of the LLP. We
use the name "RadcliffesLeBrasseur" and the abbreviation "RLB" to refer to RadcliffesLeBrasseur LLP.
Jacqueline Lake
09 September 2020
Page 2
was a presentation which covered the obstetric
The first session Dr
attended with Mrs
s reflection document that he was tested on his
emergency topics. It will be noted from Dr
understanding of how he would manage the various emergency situations by Mrs
asking him
questions about the presentation and that he found this exercise useful. This was a joint session with other
junior doctors.
The second teaching session was a one to one simulation training session which focussed on instrumental
deliveries, deeply impacted head and risks of prematurity, being areas pertinent to the matters highlighted
in the Regulation 28 report. Dr
reflection confirms that he was asked to demonstrate the correct
application of forceps in breach deliveries with the head in different positions.
confirms that Dr
Mrs
him perform a forceps delivery she is satisfied he is competent. She also provides an example of Dr
calling for assistance, appropriately, even though that assistance was not later required.
is booked to attend the PROMPT course, and that having observed
In addition to the training with Mrs
s request that he attend at
Exeter Hospital, a busier unit than at North Devon Hospital, because it is likely to expose him to obstetric
to gather greater exposure to emergency care,
emergencies. This has been arranged in order for Dr
albeit he will be an observer. This training is scheduled to occur in the next few weeks in accordance with
the consultant’s availability. In the meantime, Dr
continues to keep himself updated with the
guidance from the Royal College of Obstetrics and Gynaecology.
it has been arranged at Dr
, a Consultant Obstetrician and Gynaecologist at the North
Lastly, we enclose a letter from Mr
Devon District Hospital. Mr
having worked
alongside him during the on-call cover of Obstetrics and Gynaecology and also in various clinics and
knows the limitations of his practice and will ask for
theatres. Importantly, he too notes that Dr
assistance if required. He reports Dr
to have run labour ward emergencies with confidence. Mr
Eskandar is aware that Dr
is making every effort to update himself in all aspects of obstetric
emergencies following the inquest.
’s letter confirms that he has observed Dr
Please note that both Mr
providing a letter on behalf of Dr
inquest but were both content to provide a letter in support of Dr
actions.
received a copy of the Regulation 28 report before
. They were therefore both aware of the concerns raised at the
s wider practice and remedial
and Mrs
response to the inquest findings, you will be
We trust that in providing this information about Dr
reassured that Dr
has taken this matter very seriously indeed and has committed to improving his
knowledge and practice so as to ensure that the tragic circumstances of this case are never again repeated.
Yours faithfully
RadcliffesLeBrasseur LLP
RadcliffesLeBrasseur LLP
Encl.
Dr.
Reflection on HM Senior Coroner Report
1.
I have carefully considered the report of the Coroner and the evidence presented during the
inquest. I was troubled to understand that the Coroner had concerns about my evidence,
practice and emergency training. I have as a consequence taken steps to address what I can
and undertaken further training in obstetric emergencies. I also self-referred to the General
Medical Council and will engage with any subsequent investigation by the Council.
2. On reflection of this case, I accept that it was an option to adopt a ‘wait and see’ approach
to manage the patient rather than to proceed to a trial of instrumental delivery. I recognise
that instead of allowing an hour for the patient to be prepared for theatre, where there is no
clinical urgency, it would be better practice to leave the patient in the room and examine
her an hour later and again consider the options at that time. Where I am in any doubt
about the best way to proceed I have learnt to involve more the consultant on call.
3. My concern about the CTG was from the previous ones and the part I have seen after I have
spoken to the consultant (shortly before 2 pm), but I agree that the CTG was normal as I
have documented in the notes before speaking with the consultant. I must accept that from
, she understood that
my explanation, regardless of what I had intended and told to Dr
I was raising a concern about the CTG being abnormal at that time and that informed her
agreement to proceed to a trial instrumental delivery. This was not correct. I have learnt as
a result of this process to discuss more details about the patient with the consultant on call
and ask him/her for the advice and document this conversation separately in the notes
where the consultant is not able to also review the underlying information e.g. the CTG, for
themselves.
4.
In this case Dr
, asked me if I am happy to proceed with the procedure, as all the
consultants do when I ring them. I did not expect any problem doing the forceps or the CS as
I have performed 1000’s of each during my career and I always tell the consultant to come
and join me if I am expecting problems and will definitely call him/her if I am facing any. So
in this case I had no reason to ask Dr
to attend at the time of examination in theatre. I
would not hesitate to ask for assistance or supervision if I have any concern about possible
complications.
5.
I instructed the senior midwife to replace gently the head into the vagina while I was
changing my gloves and gown to start the C.S. I accept I should have done this myself but I
was running against time to start the C.S before the baby started to breath as in this case we
would have been in a more difficult situation. I learnt that in the future in any similar
situation I will replace the head myself inside the vagina using Zavanelli manoeuvre.
6. Regarding my training, I have always kept myself with up to date knowledge and completed
my CPD hours requested by the Royal College. Before the incident, I have attended many
CTG and departmental meetings to discuss emergency obstetrics and how to avoid mistakes.
I recognise that as a professional and particularly as a locum it is my responsibility to ensure
my training is up to date. After the incident and before the hearing, I have continued to be
up to date with my CPD points. I have set out below some of the relevant courses/ training
that I have attended:
Post March 2019 (pre-inquest)
a.
I have attended the Annual International Royal College Conference in June 2019
where all the updates in our speciality are discussed.
b. K2 training courses: As Prompt courses were not available in 2020 because of the
Covid 19 pandemic, I did the alternative K2 courses in March and April 2020. I have
passed all the 14 courses covering all the Obstetric emergencies. Each one lasts
from 30 minutes to 4 hours. Having videos, diagrams and texts and then 10-20
questions which one has to get 80% marks to pass in each course. These cover 14
subjects of obstetric emergencies such as antenatal and intrapartum CTG, errors and
limitation of fetal monitoring, shoulder dystocia, Maternal haemorrhage and
collapse, cord presentation and cord prolapse.
c.
In perinatal and audit meetings we discuss any problems that led to adverse effects
on the mother and the fetus and how to avoid them in the future.
d. The CTG meetings, I attended over the years, help me to identify abnormal CTG’s
and the proper action as discussed with the group of doctors in the department.
Also courses are useful for me to update my knowledges in the management of all
obstetric emergencies. Many of these meetings are now done online as the number
attending is very limited due to Covid 19 pandemic. Some Trusts now using a type of
software to allow the consultant to see the CTG when he is away from the hospital
but this is not available to all hospitals.
Post July 2020
a. After the inquest, I have asked my consultants at North Devon District Hospital
about arranging extra training in Emergency Obstetrics. I have attended a session
, the Clinical Lead for Labour Ward covering all obstetric
with Mrs
emergencies such as Sepsis, Pre-eclampsia, eclampsia, Thromboembolism, Obstetric
Haemorrhage, Cord prolapse and shoulder dystocia on 6 August 2020. This session
was showing online statements and diagrams and she asked me many questions on
each subject as what to do in these emergencies and about how to manage these
cases and I have passed them all. This was quite useful to update myself on all these
subjects.
b. On 13 August 2020 I attended a simulator course covering Breech delivery and
forceps delivery for different positions as OP, OA and for the after coming head in
vaginal breech delivery. I was given a model of fetus, pelvis and pair of forceps to
demonstrate how to deliver the breech in different positions and to apply the
forceps and deliver the head in different positions as OA or OP or the aftercoming
head of the breech.
c.
I will be attending the PROMPT (PRactical Obstetric Multi-Professional Training)
course when it is again available. This is practical training that has to date been
postponed as a result of Covid. However, I have in anticipation of completing such
training purchased a copy of the PROMPT training manual which I am working my
way through. I was told that Prompt is not going to be offered in its classical way
this year, but as I have completed the K2 courses in March / April this year, I was
told that I can complete the course on line to get the certificate. I did last week the
same 14 K2 subjects mentioned before but as assessments which I need to get over
80% to pass. I passed all of them at high marks. I am left only with 2 CTG simulators
which I will do next in the next few weeks and then I will complete what Prompt
needs and will get the certificate. The simulator puts me in what is called live
atmosphere with conditions that I have to assess and decide on the management
which is very useful.
d.
I requested to go to a busy unit for a day to learn more about emergency obstetrics
and they will kindly arrange for me to go to Exeter in the next few weeks when it is
convenient for the Consultant. This will allow me to see more obstetric emergencies
in one day and share in the management decision.
e.
In the next year I will attend the live prompt course which helps me to improve in
the management of obstetric emergencies and to improve communication skills.
Royal College Guidance and GMC Good Medical Practice
I always endeavour to comply with the Royal College guidance and the GMC Good Medical Practice
guidance which includes:
1. Make the care and the safety of the patient my first concern.
2. To be competent and keep my professional knowledge and skills up to date by attending
regular clinical meetings and courses.
3. Take prompt action if I think the patient safety is being compromised and ask for help if
required.
4. Establish and maintain good relationship with the patients, the nursing staff and my
colleagues.
5. Being open, honest and acting with integrity as a doctor.
Regarding the Royal College Guidelines:
a.
b.
c.
I have read all their green-top guidelines which are emailed to me frequently
and mainly in obstetric emergencies as shoulder dystocia, Antepartum and
postpartum haemorrhage, shoulder dystocia, umbilical cord prolapse and
maternal collapse.
I do regularly the Tog questions which are sent to me by the Royal College. It
consists of a subject followed by a series of multiple choice questions and you
have to get 80% to pass and get your CPD points. They cover many subjects in
Obstetrics & Gynaecology.
I attend the annual international meeting of the Royal College when held in the
UK as I did in June 2019 in London. It is an excellent chance to attend many
lectures and discussions with small group meetings about the updates in our
speciality.
I will continue to keep my practice under review as I never want a repeat of this sad case. I wish to
again send my condolences to the family of Kobi Wright.
I can confirm that I am writing the following statement following a request from Mr
and I am happy for my letter to be provided to HM Senior Coroner for Norfolk and the General
Medical Council.
I have been provided with a copy of the Regulation 28 Report to Prevent Future Deaths concerning
but I have not seen the patient’s notes or the investigation report by the hospital.
Dr
My name is Miss
Gynaecology Consultant in 2016 in North Devon District Hospital.
, I qualified as a doctor in 2003, and I became an Obstetrics and
I am the Labour Ward Lead in North Devon District Hospital and the Training Programme Director on
the South West training programme.
has worked in North Devon District Hospital on and off since the 25th of November 2019 in
Dr
a middle grade locum capacity.
He has been very proactive at requesting Obstetric emergency training and has attended two
sessions with me.
The first session of Obstetric emergencies he attended included a presentation for Obstetric
emergencies such as sepsis, shoulder dystocia, APH, PPH, cord prolapse. The session was also
attended by new junior doctors in the department and it is part of the induction for new junior
doctors.
The second teaching session was a one to one “hands on” simulation training session with myself on
instrumental deliveries, deeply impacted head and risks of prematurity.
Unfortunately our PROMPT course has been cancelled due to Covid however we are looking into
restarting this and respecting social distancing rules.
I have booked Dr
on our next PROMPT course in the NDDH.
I am also aware that Dr
has completed his K2 training for CTG and Obstetric emergencies.
I have observed Mr
competent manner.
perform a forceps delivery in theatre of a term baby and he did that in a
I am aware of an incident where he performed a second stage Caerarean section following a
Consultant’s decision in north Devon District Hospital and he had difficulty in delivering the head at
Caesarean section.
He called the Consultant and he dis-impacted the baby’s head himself and delivered the baby before
the Consultant arrived.
has been very proactive to attend Obstetric emergency training with myself and is keen to
Mr
keep up to date.
Mrs
Consultant Obstetrician & Gynaecologist
Labour Ward Lead
Risk Management Lead
College Tutor
Training Programme Director South West Peninsula
Tel :
email:
web: www.northdevonhealth.nhs.uk
Department of Obstetrics & Gynaecology North Devon District Hospital
Raleigh Park
Mr
Consultant Obstetrician & Gynaecologist Barnstaple, Devon
Tel: (01271) 322786 Fax: (01271) 311653 EX31 4JB
Tel: 01271 322577
Fax: 01271 311541
Minicom: 01271 322746
www.northdevonhealth.nhs.uk
OE/KM
28th August 2020
Re: Dr
I am writing this statement following a request from Radcliffe SLE Brasseur LLP to provide a statement
which can be provided to the HM Senior Coroner for Norfolk and General Medical Council.
for Mr
I have been made aware that Dr
provided with a copy of the regulation 28 report.
was criticised at an inquest in July 2020 and I have been
I am a Consultant Obstetrician and Gynaecologist at Northern Devon Healthcare Trust. I am the Lead
Clinician for the Obs & Gynae Department. I have FRCOG and MFSRH. I have 33 years of experience
in obstetrics and gynaecology.
Dr
joined our Obs & Gynae Department as a Locum SAS Doctor from November 2019. He has
been involved in the Middle Grade Rota and he worked with me during the on-call cover of Obstetrics &
Gynaecology and also in various clinics and theatres. I am aware that Dr
has completed the K2
Training Programme of Obstetric Emergencies which is a substitution of the PROMPT Training during
the Covid-19 pandemic. Also, I am aware that Dr
had a simulator training session with the
Labour Ward Lead including the obstetrics emergencies and instrumental deliveries. He is up to date
with his RCOG CPD. He is intending to go to Royal Devon & Exeter Hospital to have further training in
this busy hospital.
During his stay in our Department, I found Dr
a competent, experienced Obstetrician and
Gynaecologist. He ran labour ward emergencies with confidence and I am not aware of any major
incidents during his time with us. He is aware of his limitations and he asks for help when indicated. He
is aware of his current circumstances and he is making every effort to make himself updated with all
aspects of obstetric emergencies which I feel he is competent in doing so.
Yours sincerely
Mr
Consultant Obstetrician & Gynaecologist
FRCOG MFSRH
1
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