Poppy Harris

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Milton Keynes 
University Hospital 
NHS Foundation Trust 

Mr Tom Osborne 
HM  Senior Coroner 
HM Coroner's Office 
Civic Offices 
1 Saxon Gate East 
Central Milton Keynes 
MK9 3EJ 

07 December 2021 

Dear Mr Osborne 

Regulation 28:  Report to Prevent Future Deaths 

I write in response to the Regulation 28 report you issued on  20 October, following on 
from  the  Inquest  held  into  the  death  of Poppy  Harris  (on  24  March  2021)  which 
concluded on 15 October 2021 . This report was issued to me, and a further report was 
issued  to the  Royal  College  of Obstetrics  and  Gynaecology  (around  the  place  of 
Kielland's forceps in  modern obstetric practice more generally). 

The  loss  of a  healthy  baby  is  of course  profoundly  sad,  particularly  in  this  context 
where  a  clear  link can  be  drawn  between  an  assisted  I  interventional  delivery  and 
injuries sustained. Our thoughts remain with  Poppy's parents and wider family. 

You raised two specific issues which I shall address in turn: 

1.  When  Poppy's mum came into  the hospital,  she did not have a  birth plan and the 
midwives did not attempt to complete one.  There was therefore no indication as to her 
preferences for treatment and care throughout her labour. 

There are two contextual factors which should be considered: 

a.  MKUH,  and  many  other  NHS  organisations,  are  adopting. electronic  health 
records  (in our case,  Gerner).  There are substantial patient safety benefits.  In 
maternity care,  a specific challenge arises as the electronic health record  was 
preceded by a paper record held (predominantly) by the mother rather than the 
hospital.  We continue to work to optimise the  balance between the risks  and 

As o leaching hospitol. we conduct education ond research to improve heolthcare for our 
patients. During your visil students may be involved in your care, or you moy be osked 10 
porticipale in a clinical trial. Please speak to your doctor or nurse If you have any concerns. 

 TheMK 

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Milton Keynes
University Hospital 
NHS Foundation Trust 

benefits  of an  electronic  health  record  and  the  (appropriate)  requirement  for 
mothers to have ready access to their record . 

b.  The ongoing COVID-19 pandemic continues to have an impact on the maternity 
pathway  (specifically  in  relation  to  the  use  of  virtual  platforms  for  some 
traditionally physical maternity contacts). 

Following on from  Poppy's inquest- and recognising the need to take stock following 
on  from  iterative  changes  to  maternity pathways  over the  course  of the  COVID-19 
pandemic  - we  have  undertaken  a  review  of  how  we  ensure  that  women's  birth 
preferences are discussed and documented. 

As part of their routine antenatal care, women are seen by their community midwife at 
approximately  30  weeks  of  pregnancy  (precise  timing  varies  according  to  first  / 
subsequent  pregnancy),  and  again  at  34  weeks.  Going  forward,  this  area  will  be 
addressed specifically at these two points. At the 30-week appointment, women will 
be  provided with access (via an  internet URL/ QR code) to a specific section on the 
MKUH  maternity website where  a  repository of leaflets  relevant to aspects  of birth, 
along with short videos about each of the topics, will be placed. 

These leaflets and videos will include - but will not be limited to: 

• 
• 

• 
• 
• 
• 
• 
• 
• 
• 

Meet the team 
Pain  relief in labour 
Waterbirth 
Epidural 
Monitoring your baby's heartbeat 
Assisted vaginal birth  (RCOG) 
Caesarean section 
OASI  (obstetric anal sphincter injury) 
Perineal care 
Vitamin K 
Newborn feeding 

The  woman  will  be  encouraged  to  read  the  leaflets  and/or  review  the  videos  in 
preparation  for  a  structured  discussion  about  birth  preferences  at  the  34-week 
appointment. 

As o teaching hospttol, we conduct educolion end ieseorch IO improve heolthcore fOf our 
polients. During your visit students moy be involved in your core, or you moy be oslced to 
participate in o clinical trlol. Please speak to your doctor or nurse if you hove any concerns. 

 TheMK 

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University Hospital 
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At 34 weeks,  the length of the appointment will be extended from  20 minutes to one 
hour.  In this time,  the midwife will  complete the routine antenatal checks and discuss 
the woman's questions, wishes and birth preferences, recording this on a standardised 
form.  The  design  of  the  form  will  have  input  from  the  local  Maternity  Voices 
Partnership.  We  will  keep  abreast of regional  and  national  initiatives  and  consider 
reverting to a standardised process as and when established. 

In the first instance, the form  will  be  completed  by the  midwife within  the  electronic 
patient record,  and  a printed copy will be given to the woman for inclusion within  her 
handheld record. 

We  will ensure that particular care is  taken  to facilitate this 34-week discussion  (and 
share the underlying information resources) for those with disabilities and/or for whom 
English is not a first language. 

2.  Poppy was delivered by the use of Kie/land's forceps that resulted in a catastrophic 
spinal cord injury.  I believe the hospital should carry out an urgent review of the use 
of Kie/land's forceps and decide that they should not longer be used. 

As you are aware,  Kielland's rotational forceps  are used by a subset of obstetricians 
in  England (i.e.,  the use of Kielland's rotational forceps is not a required competency 
for all consultant obstetricians). Their use tends to be concentrated in  some units and 
they may  be  absent in  others.  As with  most interventions,  professional  opinion  and 
some evidence supports a relationship between volume and outcomes: in capable and 
experienced  hands,  Kielland's rotational forceps can  assist in  achieving safe vaginal 
delivery thus reducing the need for emergency Caesarean section (and the risks that 
this carries for the mother in particular). 

In  recent  years,  two  consultant  practitioners  at MKUH  have  been  regular  users  of 
Kielland's  forceps  in  appropriate  cases.  The  use  of Kielland's  at MKUH  has  been 
paused since Poppy's delivery on 23 November 2020. 

Whilst  we  naturally  seek  to  take  on  any  learning  from  Inquest  findings,  the  local 
Coronial  process  is  not in  my view the appropriate route through which to determine 
future patterns of medical practice. Such decisions require appropriate assessment of 
risks  and  benefits  of  multiple  treatment  modalities,  drawing  upon  evidence  and 
professional opinion. We will await the response of RCOG to your Regulation 28 report 
with interest and will determine our position at that point. 

As a teaching hospital, we conduct education and research la improve healthcare lo, olK 
patients. During your visit students may be involved in your care, oryou may be asked lo 
particlpole in a clinical trial. Please speak lo your doctor or nurse if you hove any concerns. 

 TheMK 

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Milton Keynes 
University Hospital 
NHS Foundation Trust 

I believe that it is unlikely that RCOG will advocate the  removal  of rotational forceps 
from  practice.  In that event,  and  if individual  clinicians wish to maintain the option of 
rotational forceps in their repertoire, we will support them in doing so. We will of course 
ensure that discussions are held in appropriate fora (departmental clinical governance 
meetings and  individual  professional appraisal) to ensure that knowledge,  skills,  and 
volumes  meet  recommendations  of  RCOG  and/or  regional  obstetric  leads.  If 
consultant practitioners continue to use Kielland's forceps, we will also permit them to 
train junior colleagues in their use (taking into account relevant guidance from Health 
Education England and others). 

I hope that this response is helpful. 

Yours sincerely, 

Chief Executive Officer 

Copy - Care Quality Commission 

As a teaching hospital. we conduct education and research to improve healthcare for our 
patien1s. During your visit students may be involved in your care, or you may be asked to 
por1icipote in a cinicol 1rial. Please speak to you, doclor or nurse if you have any concerns.