Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0425, written 17 Dec 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Dec 2021 |
|---|---|
| Reference | 2021-0425 |
| Deceased | Ziggy Mitchell-Stagg |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Child Death (from 2015) |
| Organisation named | Homerton University Hospital NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Homerton University Hospital Homerton Row London E9 6SR www.homerton.nhs.uk Her Majesty’s Coroner for Inner North London HM Coroner’s Court Poplar 127 Poplar High Street London E14 0AE 9th February 2022 Dear Madam Regulation 28: Prevention of Future Deaths Report Response Deceased: Ziggy MITCHELL-STAGG (died 04.04.2021) I am writing in response to your Prevention of Future Deaths Report issued to the Trust following the Conclusion of the inquest into the death of Ziggy Mitchell-Stagg. You raised four concerns in your letter which I hope will be addressed below. 1. There was not standardisation of the terminology used by the midwives and obstetricians to describe meconium found, and the information requested by the computer system to record this did not necessarily reflect the verbal descriptions. Sometimes grades I, II & III were used; sometimes significant and insignificant, thick or thin. There was also inconsistency as to whether grade II was significant, and whether the term significant referred purely to the meconium noted, or to the meconium in the context of other features. The Trust accepts that during the course of the treatment of Ziggy’s mother and the inquest, the terminology used to describe meconium was inconsistent. A few actions will be taking place to ensure more consistency in the maternity department: a) Our computer system upgrade was already in place before the inquest, and one of the upgrades included updating the meconium grading from Grade I, II & III to the new system of Significant and Insignificant. The Trust has approved this change. A text box will now flash up once significant/insignificant is selected that will allow the clinician to enter the reason why they made that selection and whether any onward action/escalation is needed. This change has been finalised and will be implemented by March 2022. b) As stated above, the Trust acknowledges that the grading of meconium is not up to date and is inconsistent. We therefore plan to hold a ‘Meconium Awareness Month’ where the following will happen:- • • • policies that require upgrading (from Grade I, II & III to significant/insignificant) will be circulated, once updated and agreed; the new upgrade mentioned in (a) above will be rolled out; specific training will be delivered on identifying significant/insignificant meconium and ensuring staff are no longer using the old grading system for communication and note taking; Incorporating hospital and community health services, teaching and research - 2 - • daily safety huddles and handovers will ensure that staff are reminded of this change • and will be encouraged to take time to review all the changes; the Practice Development Midwives (PDM’s) will provide learning specifically from this case. We are making plans for this awareness month will take place in March 2022. 2. The obstetric registrar attending to Ziggy’s mum did not make any notes in the medical records after 3.46am, even retrospectively. The obstetric registrar has been spoken to by her relevant manager and it has been agreed that she will attend an external course on documentation. Our in-house legal team provide training to the midwifery team on a monthly basis on the importance of documentation and this training will now be delivered to the doctors on a quarterly basis as well. The legal team will be delivering their first session on the 25th February 2022 where all doctors that cared for Ziggy’s mum will be in attendance and this case will be discussed. 3. I was told that your trust does not have a local policy regarding the use of centralised CTG monitoring, and it seems such a policy merits consideration. A Policy has been drafted and has been signed off and approved. This will be circulated via an email to all staff and will be part of the daily handovers. 4. There is national guidance that there should be a fresh eyes review every hour for women in labour, but your trust policy indicates only every two hours. It seems that the trust policy merits reconsideration, either to amend it or to record why there is a departure from national guidance. The trust realises that the hourly ‘fresh eyes’ review is embedded within national guidance and we want to strive to achieve this. The trust previously trialled this in 2019 however it was found that a true fresh eyes review was not achievable every hour. We agree that our Trust guidance needs revisiting and our first step in that process is to liaise with other neighbouring Trusts of similar acuity to learn from them and understand how they adhere to an hourly fresh eyes which not only assesses fetal well-being but provides a holistic view. We will then create our own action plan for implementation. We trust that this answers all of your concerns and we are grateful for these issues being highlighted to us so that we can improve patient safety. Yours faithfully Dr Medical Director
Regulation 28: Prevention of Future Deaths report Ziggy Dylan MITCHELL-STAGG (died 04.04.21) THIS REPORT IS BEING SENT TO: 1. Dr Medical Director Homerton University Hospital NHS Trust Homerton Row London E9 6SR 1 CORONER I am: Coroner ME Hassell Senior Coroner Inner North London St Pancras Coroner’s Court Camley Street London N1C 4PP 2 CORONER’S LEGAL POWERS I make this report under the Coroners and Justice Act 2009, paragraph 7, Schedule 5, and The Coroners (Investigations) Regulations 2013, regulations 28 and 29. 3 INVESTIGATION and INQUEST On 14 April 2021, I commenced an investigation into the death of Ziggy Mitchell-Stagg, a baby who died a few hours after birth. The investigation concluded at the end of the two day inquest on 15 December 2021. I made a determination of death by natural causes. The medical cause of Ziggy’s death was: 1a) perinatal asphyxia 2 chorioamnionitis with funisitis, and macrosomia 4 CIRCUMSTANCES OF THE DEATH Ziggy’s mum presented to Homerton University Hospital on 3 April 2021. Ziggy was born by emergency Caesarean section at 5.28am in a very compromised state, and died a few hours later. 1 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. There was not standardisation of the terminology used by the midwives and obstetricians to describe the meconium found, and the information requested by the computer system to record this did not necessarily reflect the verbal descriptions. Sometimes grades I, II & III were used; sometimes significant & insignificant; sometimes thick or thin. There was also inconsistency as to whether grade II was significant, and whether the term significant referred purely to the meconium noted, or to the meconium in the context of other features. 2. The obstetric registrar attending Ziggy’s mum did not make any note in the medical records after 3.46am, even retrospectively. 3. I was told that your trust does not have a local policy regarding the use of centralised CTG monitoring, and it seems that such a policy merits consideration. 4. There is national guidance that there should be a fresh eyes review every hour for women in labour, but your trust policy indicates only every two hours. It seems that the trust policy merits reconsideration, either to amend it or to record why there is a departure from national guidance. 6 ACTION SHOULD BE TAKEN In my opinion, action should be taken to prevent future deaths and I believe that 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 14 February 2021. I, the coroner, may extend the period. 2 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 following. • • The Healthcare Safety Investigation Branch (HSIB) , obstetric consultant, HUH • Dr • Dr , obstetric registrar, HUH • HHJ Thomas Teague QC, the Chief Coroner of England & Wales Ziggy’s parents I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. 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. 9 DATE SIGNED BY SENIOR CORONER 17.12.21 ME Hassell 3
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