Wynter Andrews

Please ask for the Medical Director’s Personal Assistant 

Our Ref:  

4th December 2020 

STRICTLY CONFIDENTIAL 

Miss Laurinda Bower 
HM Assistant Coroner for Nottingham City and Nottinghamshire 
HM Coroner’s Court 
The Council House 
Market Square 
Nottingham   NG1 2DT 

Dear Miss Bower 

Medical Director’s Office 
3rd Floor, Trust Headquarters
City Hospital Campus 
Hucknall Road 
Nottingham 
NG5 1PB 

Tel: 

Email: 

www.nuh.nhs.uk 

Inquest: Wynter Andrews and Prevention of Future Death Notification 

Please find attached a commentary that I have prepared in response to the Preventing Future Deaths 
Report  issued  to  Nottingham  University  Hospitals  following  the  inquest  into  the  death  of  Wynter 
Andrews.  

I was not present at the inquest but note that there are two broad matters of concern identified in the 
PFD notification. 

My  response  to  each  of  the  concerns  identified  in  the  PFD  have  been  informed  following  work 
undertaken  by  colleagues  involved  in  the  Midwifery  Service  and  Family  Health  Division  and  other 
individuals  and  teams  in  the  organisation  including  the  Chief  Nurse,  the  newly  appointed  Senior 
Responsible  Officer  for  our  Maternity  Transformation  programme,  the  Associate  Director  of  Quality 
Governance and the Head of Patient Safety. 

The  actions  either  taken  or  planned  in  response  to  the  learning  from  the  inquest  are  summarised 
below.  The  oversight  of  the  delivery  of  these  actions  will  be  through  a  newly  formed  Maternity 
Programme Oversight  Committee  chaired  by  the  Chief  Executive  Officer  and  the  Quality  and Safety 
work  stream  of  this,  which  I  Chair.  The  Quality  Assurance  Committee  of  the  Board  will  be  receiving 
reports on progress and the full Board will be kept informed. 

I hope that this commentary provides assurance that we are committed to learning from this, and other 
incidents  to  significantly  enhance  the  care  of  mothers  and  their  babies  at  Nottingham  University 
Hospitals NHS Trust. 

Yours sincerely 

Dr 
Medical Director   
GMC Number 

cc: 
Ambassador, 
Commissioning Group. 

, Chief Nurse, 

, Inspector and CQC Freedom to Speak up 
,  Head  of  Quality,  NHS  Nottingham  and  Nottinghamshire  Clinical 

 
 
 
 
 
 
 
 Response to concerns identified through the PFD 

(1)  Lack of robust initial critical analysis of deaths 

NUH Response  

Coroner Referral and Scrutiny of Deaths 

The Trust has a well-established Medical Examiner service, comprising eight Medical Examiners, who 
provide independent scrutiny of all adult deaths. 

At  the  time  of  WA’s  death,  all  deaths  of  children  were  reported  to  the  Senior  Coroner  for 
Nottinghamshire. Scrutiny of child and neonatal deaths by the Medical Examiners did not commence 
until after the 1st October 2019, in accordance with guidance issued by the Chief Coroner. Since that 
date,  all  neonatal  and  child  deaths  at  Nottingham  University  Hospitals  have  been  reported  to  the 
Medical  Examiner  service  including  all  babies  born  showing  signs  of  life at  any  gestation.  The  well-
established Child Death Review Process (CDRP) continues to run in parallel but the Medical Examiner 
scrutiny  takes  precedence  (within  the  first  24  –  48  hours)  in  order  that  this  independent  review  is 
completed  as  quickly  as  possible.  This  includes  ensuring  that,  where  there  is  a  clear  reason  for 
notifying the Senior Coroner, this is achieved at the earliest opportunity. The work of the ME Service 
now provides independent scrutiny of all neonatal and child deaths in a way that was not in place at 
the time of the death of baby WA.  

Having considered the matters of concern in the Preventing Future Deaths report it is now determined 
that  the  processes  in  support  of  early  review/scrutiny  by  the  Medical  Examiners  can  be  further 
strengthened through a number of planned improvements, outlined below. Unless otherwise stated all 
actions will be complete by 1st February 2021: 

  Broadening  understanding  of  the  Medical  Examiner  process  through  more  widely  engaging 
maternity  and paediatric  staff  through  training  and  awareness seminars.  There will  be  sharing  of 
expectations  of  information  needed  by  the  Medical  Examiner  for  early  and  robust  collection  of 
and 
relevant 
parents/carers/family.  

from  Neonatologists,  Paediatricians,  Midwives,  Obstetricians 

details 

  Community midwives are moving from System 1 (a GP community system) to Maternity Medway 
(the  NUH  digital  record  software)  which  will  increase  digitalisation  of  the  antenatal  pathway  and 
increased  visibility  of  the  care  record.  This  is  a  substantial  change  and  will  be  complete  by  4th 
January 2021.  

  The  initial  Child  Death  Review  (CDR)  /  Medical  Examiner  (ME)  referral  form  will  be  changed  to 
include space for all professionals involved in a child’s antenatal and postnatal care to be clearly 
identified. This will support the Medical Examiner team to contact relevant clinical teams and gain 
information in person and from records.  

  The  Medical  Examiner  Service  will  make  contact  with  all  bereaved  families  in  order  to 
independently  ascertain  the  details  of  any  concerns.  The  child  bereavement  booklets  given  to 
parents  will  be  modified  to  include  Child  Bereavement  and  Medical  Examiner  team  contacts. 
Wherever possible, the Medical Examiner will talk to families the next working day after a child’s 
death.  

  An  early  multidisciplinary  review  meeting  will,  wherever  possible,  take  place  within  five  working 
days  of  the  child’s  death  to gather  the  team  involved  in  the  antenatal  and  post-natal  care  of  the 
mother and child. This meeting will invite the CDR/ME professionals, allowing further collection of 
detailed  information  and  review  of  any  concerns  of  care,  including  representation  of  the  parents’ 
views of care.  

 
 
 
 
 
 
 
 
 
 
   The Multidisciplinary Team (MDT) Case Review Meeting in maternity (held every Monday) will be 
reviewed  and  strengthened  by  promoting  inclusivity,  the  voice  of  the  clinical  midwives  and  the 
views of the parents.  The review will form part of the Trusts recently convened (November 2020) 
Maternity Transformation Governance Group. 

Revisions to the Trust incident escalation report (formerly referred to as the 72 hour report) 

At the current time, when an incident has occurred that might meet the threshold for an investigation 
within  the  Serious  Incident  Framework,  an  initial  “72-hour  report”  is  completed  and  presented  at  a 
weekly Trust multi-disciplinary Incident Review Meeting. The initial “72-hour report” has been modified 
to now contain prompts to ensure that wider review of potential information is considered in the context 
of  an  individual  case  (for  example  complaints/concerns,  claims,  known  risks  on  risk  register,  
Structured Judgement Case Review learning, consideration of previous similar events and contextual 
incidents/events).  

It is expected that this change will result in a broader review of the context in which an incident occurs, 
in addition to the specific adverse event itself. Care quality ratings [from excellent to very poor] across 
the  patient’s  pathway  have  been  included  to  strengthen  the  review.  The  escalation  report  has  been 
updated to provide guidance on the definitions of a Serious Incident [with links to the national Serious 
Incident framework].  

To further support the identification of cases (maternity or otherwise) which may meet the criteria for a 
Serious Incident Investigation, a digital application has been built that pulls data from multiple sources 
to  help  identify  possible  high  risk  cases.  This  would  include,  for  example,  where  there  may  be  a 
concurrent  incident,  complaint  and  claim.  The  application  consolidates  internal  data  in  relation  to 
patient deaths, formal complaints, family concerns, patient safety incidents, coroner’s inquests, clinical 
negligence claims and maternity early notifications. 

In  addition,  in  support  of  the  Multidisciplinary  Team  (MDT)  Case  Review  Meeting  in  maternity,  the 
Perinatal Mortality Review Tool (PRMT) will be used to inform the case review discussions. The PMRT 
is a national standardised tool designed to support high quality, systematic, mulitprofessional reviews 
of  stillbirths  and  neonatal  deaths  that  take  into  account  the  views  of  the  parents.  The  output  of  the 
reviews is the production of a report for parents that includes a plain English explanation of why their 
baby died and whether the care was appropriate.  Full completion of the PMRT requires input from the 
parents,  placental  histology  and post-mortem reports  which can  take  several  months  to  be returned. 
The use of a live version including all available information to date, to inform the case review meeting, 
is being piloted.  

Classification of Serious Incidents [Maternity] 

The national Serious Incident Framework (2015) does not provide an explicit list of triggers/categories 
that would indicate a case should be declared and investigated as a Serious Incident (SI). In response 
to the national focus on reducing stillbirths and following the delay to declaring the WA case a Serious 
Incident, the Trust has decided to declare unexpected early [term] neonatal deaths [HSIB define this 
as days 0-6] and intrapartum term stillbirths as Serious Incidents. This process will exclude babies on 
an identified care pathway with life-limiting conditions including congenital abnormalities, except where 
there has been a deviation from the pathway that requires further investigation. 

This  decision  takes  the  Nottingham  University  Hospitals’  approach  beyond  that  required  by  the 
national Serious Incident framework but provides assurance that a full investigation of all such cases is 
being  undertaken.    We  will  keep  this  decision  under  review  in  light  of  any  future  changes  to  the 
Serious Incident Framework. 

(2)  The unsafe culture prevailing within Midwifery Services 

 
 
 
 
 
 
 
 
 
 (a)  Failure to listen to and respond to staff safety concerns 

NUH Response  

Safe culture work: 

  In  December  2019,  a  Birthrate  Plus  (BR+)  staffing  review  on  maternity  services  was  undertaken. 
The  NUH  report  by  the  national  body  undertaking  this  work  was  published  in  June  2020.  This 
highlighted that, when considering the acuity of care required in the maternity services, there was a 
shortfall  in  the  midwifery  staffing  establishment  of  73  Whole  Time  Equivalent  (WTE).    We  have 
been recruiting to resolve this issue and fifteen newly qualified midwives commenced in September, 
23.84  WTE  new  starters  were  recruited  in  late  October  (26  individuals)  and  will  start  in  January 
2021.  A further recruitment campaign is underway.  Agency staff and overtime have been offered 
to bridge the gap in the interim.  Staffing levels and acuity are being monitored daily, and activity 
diverted or reduced, or staff redeployed, as necessary to maintain safe staffing levels.  

  The  visibility  of  the  work  of  the  Freedom  to  Speak  Up  Guardian  has  been  increased  within 
maternity including posters in clinical and non-patient facing areas.  A number of “maternity we are 
listening” events have been held during November and December where staff can book one to one 
meetings with the guardian. 

  The  midwife in charge  of  each clinical  area completes  a  safe  staffing  application  for  each clinical 
shift.  In addition the labour suite coordinator completes a midwifery acuity tool every three hours.  
If  a  clinical  area  is  declared  unsafe  for  staffing,  the  Maternity  Escalation  Guideline  describes 
subsequent  decision  making  and  escalation  actions.    The  local  manager’s  decision  around  safe 
staffing is supported and not changed.  Escalation actions involve redeployment of staff to support 
safe  care,  delay  in  elective  work,  diversion  of  services  to  the  other  campus  or  closure  of  both 
Maternity Units and possible redirection to other units.  

  A medical obstetric handover checklist is being piloted and will include a question for the outgoing 
medical team regarding whether they have been able to take breaks.  This will be used, along with 
the midwifery acuity, to assess the safe staffing of the unit for the preceding 12 hour period. 

  A  weekly  review  of  incidents  reported  on  Datix  is  being  undertaken  by  the  maternity  governance 
team.  This includes a review of themes and actions. Feedback of learning to staff commenced on 
1st November 2020.  

Safe Today Process: 

A member of the Senior Leadership Team, reporting directly to the Director of Midwifery and Divisional 
Director, visits both sites (QMC and City) twice daily to assess staffing and acuity.  They do this by: 

  Working  with  the  midwife  in  charge  to  complete  a  board  round  which  includes  all  in-patient 
areas  to establish acuity and activity, planned vs actual staffing and identification of NICE Red 
Flags (available online at: https://www.nice.org.uk/guidance/ng4) 

  Ensuring that the triage area is staffed and that telephone triage is prioritised, the telephone is 
answered promptly  and women  are  advised  to  attend  immediately.   The appointment  system 
for maternity triage has been discontinued. 

A Safe Today template is completed twice daily following the visits and includes any escalation plans 
that  may  be  necessary.  The  Safe  Today  visits  provide  twice-daily  assessments  of  safety  and  that 
women  and  babies  are  being  cared  for  appropriately.    The  template  records  whether  women  are 

 
 
 
 
 
 
 
 
 
 receiving 1 to 1 care in labour, whether the buddying system for CTGs is in place and operational and 
whether any patient safety incidents have occurred. 

The  Safe Today  process  informs  twice  daily  safety  briefings  sent  to  the  Chief  Executive  Officer  and 
Chief Nurse which respond to four key questions: 

  What assurance has been sought? 
  Which senior leadership is on site today? 
  Any issues and mitigation? 
  How are staff feeling? 

(b) Failure to promote and facilitate professional challenge 

NUH Response  

  We  have  developed  a  multidisciplinary  maternity  transformation  team  who  are  working  with  the 
human factors experts from the Trent Simulation Centre to incorporate knowledge of human factors 
science throughout the maternity improvement plan.  

  We  have  developed  a  training  session  for  staff  based  around  CTG  interpretation,  which  includes 
the  use  of  SBAR  handover,  and  tools  for  escalation  and  professional  challenge.  This  training 
package is currently being piloted with the intention of launching online training by mid December 
2020. An associated competency assessment will test the application of these concepts.  

  We  will  embed  these  concepts  into  staff  multi-professional  emergency  training  and  in  situ  skills 

drills.  

  The NUH Maternity Communication guideline will be updated to include the above concepts, with a 

draft to be reviewed in January 2021. 

  In December we have commenced a series of communication events allowing staff to meet directly 

with the leadership team, in which staff have been encouraged to raise professional challenge. 

  A project plan is now being created to implement Safety Huddles within the labour wards.  This is 
based on NHS Improvement best practice and we are expecting these to be established in the next 
6-8 weeks. 

(c)  Failure to reach decisions based on individualised patient risk 

NUH Response  

We recognise that our current mixed digital and paper records may act as a barrier to staff accessing 
the medical record for the full pregnancy pathway.  Actions are being taken to resolve this include: 

  Review of IT hardware to ensure mobile computers are available for ward rounds in all areas. 
  Community  midwives  to  enter  information  onto  Maternity  Medway  IT  system  so  that  information 

about the whole care pathway is available to both community midwives and hospital staff. 

  Observational  audit  to  include  an  assessment  of  whether  the  digital  records  are  accessed  and 

feedback to be provided. 

  Procurement  of  a  new  maternity  system  to  reduce  switching  and  duplication  between  paper  and 

digital records. 

  NUH is purchasing the Perinatal Institute intrapartum notes.  The notes include specific sections on 
maternal  preferences  and  documentation  of  the  risks  and  benefits  of  any  proposed  procedure  or 

 
 
 
 
 
 
 
 
 
 
 
 intervention.  This will act as a discussion prompt for staff providing intrapartum care and support 
improved documentation.   

Guidance has been changed to prevent staff providing strong opiate medication in the latent phase of 
labour  without  a  face-to-face  review  of  the  woman  by  an  obstetrician.    Midwives  are  unable  to 
administer strong opiates during the latent phase of labour without a medical prescription.  Compliance 
with this has been audited and this will be repeated in January 2021.  

The  intrapartum  risk  assessment  document  has  been  updated  and  has  been  launched  with 
accompanying staff education. The document is to be completed each time a woman presents in  the 
latent phase or established labour.  To evidence this, the maternity record keeping audit tool that is in 
development includes a question to assess compliance with this requirement. 

A checklist has been developed for the obstetric shift handover in conjunction with the patient safety 
and  acute  rescue  team  fellow  at  NUH.    This  includes  attendance  of  the  band  7  midwife  and  the 
anaesthetist as well as the obstetric team.  The discussion involves an SBAR (structured) handover of 
all  women  on  the  main  labour  suite,  Sanctuary  (Alongside  Midwifery-Led  Unit)  and  an  overview  of 
triage and the inpatient wards.  The handover checklist was launched on 16th November. 

The obstetric team will review all women on the main labour suite who require obstetric input with the 
midwife co-ordinator and anaesthetist.  Following this, the midwife co-ordinator will review the records 
(paper and digital) of other women on the labour suite and the Sanctuary with the woman’s midwife. 

Summary: 

The actions set out above are intended to address the matters of concern identified in the Preventing 
Future Deaths report in relation to: 1. Lack of robust initial critical analysis of deaths and 2. The unsafe 
culture prevailing within Midwifery services. Some of these have already been implemented and dates 
have been provided for completion of the remainder.  As Medical Director, I will be chairing the Safety 
and Quality workstream of the Maternity Programme Oversight Committee, where these actions will be 
monitored.