Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0173, written 9 Sep 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 Sep 2020 |
|---|---|
| Reference | 2020-0173 |
| Deceased | Frederick Terry |
| Coroner | Caroline Beasley-Murray |
| Coroner area | Essex |
| Category | Child Death (from 2015) · Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Mid and South Essex NHS Foundation 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 (2) NOTE: This form is to be used before an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Mid and South Essex NHS Foundation Trust 1 CORONER I am Caroline Beasley-Murray, senior coroner for the coroner area of Essex 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 On 16 November 2019 I commenced an investigation into the death of baby Frederick Joseph Terry. I decided to make this report during the investigation stage prior to reopening the inquest touching upon baby Terry’s death. On 4 September 2020 I reopened the inquest and I heard evidence relating to the specific issue as to whether or not baby Freddie was stillborn. I found as a fact that baby Freddie was stillborn, I called no further evidence and I concluded in box 4 on the Record of Inquest that Frederick Joseph Terry was stillborn. 4 CIRCUMSTANCES OF THE DEATH Baby Frederick Joseph Terry was delivered by caesarean section, after a failed forceps attempted delivery on 16 November 2019 and death was confirmed after 40 minutes of resuscitation attempts. The cause of death at post mortem examination has been given as:- 1a) hypovolaemic shock 1b) skull fracture and scalp laceration and haemorrhage 1c) birth trauma The evidence showed that baby Freddie’s very serious scalp and brain injuries were sustained during the failed forceps attempted delivery and, but for these, baby Freddie would have survived as a perfectly formed, healthy baby. CORONER’S CONCERNS 5 During the course of the investigation my inquiries 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. Continued …. The MATTERS OF CONCERN are as follows. – [BRIEF SUMMARY OF MATTERS OF CONCERN] Independent expert opinion has drawn attention to the following areas of concern • Lack of risk assessment leading to the options available to mothers as to delivery • Forceps delivery was attempted without recognising an occipito- posterior position. More training in this respect is required and the use of scans developed. • The injuries imply an excessive degree of force in the application of the forceps and the traction • Concerns about the engagement and induction of locum staff and management of staff levels on the maternity ward • The need for a bleep in the neonatal unit • Accuracy of record keeping • Training and procedures in respect of how communications should occur between all clinical personnel in the delivery theatre • Training and procedures in respect of how communications with the family should be carried out. This should cover the duty of candour. • Availability and suitability of resuscitation equipment and procedures on the maternity ward. The Trust’s Neonatal Resuscitation Policy may need to be revisited • The Trust’s Action Plan must be rigorously carried out • It would have been helpful for there to have been, during the course of the inquest, an exploration, in the course of evidence, of the treatment and care provided to baby Freddie and his parents at the time of delivery. Currently there is no legislation to cover the holding of a coroner’s inquest into a stillbirth. In March 2019, HM Government issued a Consultation on coronial investigations of stillbirths It would be helpful for this important topic to be progressed, whatever the ultimate jurisdictional decisions. 6 ACTION SHOULD BE TAKEN In my opinion urgent 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 4th November 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 who may find it useful or of interest. Mr The Ministry of Justice The Medical Defence Union Continued…. 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 [DATE] 9 September 2020 SIGNED BY HM Senior Coroner Mrs Caroline Beasley-Murray
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.
Broomfield Hospital
Court Road
Broomfield
Chelmsford
Essex
CM1 7ET
Tel No
03 November 2020
Mrs Caroline Beasley-Murray
HM Senior Coroner
Essex Coroner’s Court
Seax House, Victoria Road South
Chelmsford
Essex, CM1 1LX
By email only to:
Dear Mrs Beasley-Murray
Response to Regulation 28: Report to Prevent Future Deaths (2)
Following the Inquest touching upon the death of baby Frederick Joseph Terry and your subsequent imposition to
regulation 28: Report to Prevent Future Deaths (dated 9th September 2020), I write to advise you of the actions
that Mid and South Essex NHS Foundation Trust’s maternity services have made.
I am grateful that you have identified the main areas of concern, namely that the independent expert opinion has
drawn attention to the following areas of concern:
Lack of risk assessment leading to the options available to mothers as to delivery.
1.
2. Forceps delivery was attempted without recognising an occipito-posterior position. More training in this
respect is required and the use of scans developed.
3. The injuries imply an excessive degree of force in the application of the forceps and the traction
4. Concerns about the engagement and induction of locum staff and management of staff levels on the
maternity ward
5. The need for a bleep in the neonatal unit
6. Accuracy of record keeping
7. Training and procedures in respect of how communications should occur between all clinical personnel in
the delivery theatre
8. Training and procedures in respect of how communications with the family should be carried out. This
should cover the duty of candour.
1
9. Availability and suitability of resuscitation equipment and procedures on the maternity ward. The Trust’s
Neonatal Resuscitation Policy may need to be revisited
10. The Trust’s Action Plan must be rigorously carried out
11. It would have been helpful for there to have been, during the course of the inquest, an exploration, in the
course of evidence, of the treatment and care provided to baby Freddie and his parents at the time of
delivery. Currently there is no legislation to cover the holding of a coroner’s inquest into a stillbirth. In
March 2019, HM Government issued a Consultation on coronial investigations of stillbirths It would be
helpful for this important topic to be progressed, whatever the ultimate jurisdictional decisions.
Your Regulation 28 Report recommended that Mid Essex maternity services needed to take action to prevent
future deaths occurring. I have set out below Mid and South Essex NHS Foundation Trust’s maternity services
responses to the issues highlighted above.
The guidelines have been updated to reflect the Royal College of Obstetricians and Gynaecologists recent
guideline on Assisted Vaginal Birth (April, 2020)1, this includes a risk assessment to assist with decision making for
an assisted vaginal birth, an improved documentation pro forma following an assisted vaginal birth and reference
to ensuring that the baby’s head is checked immediately at birth for signs of trauma when obstetric instruments
have been applied.
The patient’s records Antenatal Care Record have been updated to include patient information leaflets in relation
to Caesarean Section and Assisted Vaginal Birth and the ‘assisted Vaginal Birth Record’ has replaced the
‘Operative Vaginal Delivery’ page in the ‘Operative Delivery and Theatre Care Record’.
Training in the use of ultrasound to define the fetal position as part of the risk assessment has been implemented
with specific training by ,on the use and application of obstetric instruments.
Situational awareness and communication forms part of the midwives, doctors and nurses mandatory training
programme.
Processes have been strengthened with a specific Obstetrics and Gynaecology locum checklist in place, with one
additional paid hour to complete and a self-assessment tool for obstetric technical skills has been added to the
locum recruitment vetting process. The Trust has also employed a further Obstetric Consultant on a 1 year basis
(whilst MSE reconfiguration in place). The Senior Nurse in the Neonatal unit now carries a 24 hour bleep and is
summoned as required using the ‘Code Blue’ emergency call.
To endorse effective communication in theatres the ‘Below Ten Thousand Feet’ initiative has been driven with an
aim on focussing on immediate safety concerns, this is used in conjunction with the SBAR communication tool.
To ensure effectiveness of the measures audits will be undertaken, such as an ongoing audit of unsuccessful
vaginal births and a monthly audit of the maternity acuity tool to demonstrate high activity, safety mitigation
strategies and escalation.
Learning from the incident has been shared across the Trust through a patient Safety Alert and the action plan
has been scheduled for discussion at formal meeting within the division, the Trust and the Maternity Network
region, this will continue until the actions have been completed.
Please find the evidence to address the concerns raised within the action plan with evidence of the
corresponding actions.
2
I hope that this response helps to assure you of Mid and South Essex NHS Foundation Trust’s maternity services
commitment to continuous improvement. As specified within the Prevention of Future Deaths Order, the
response has been sent within the 56 day duty period.
Yours sincerely
Chief Executive
Reference:
1.
, on behalf of the Royal College of Obstetricians Gynaecologists. Assisted
Vaginal Birth.
3
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