Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0069, written 4 Mar 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Mar 2022 |
|---|---|
| Reference | 2022-0069 |
| Deceased | Edward Akroyd |
| Coroner | Mary Burke |
| Coroner area | West Yorkshire Western |
| Category | Child Death (from 2015) · Hospital Death (Clinical Procedures and medical management) related deaths |
| 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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 The Chief Executive of Calderdale And Huddersfield Foundation Trust 1 CORONER I am Mary T. BURKEfor the coroner area of West Yorkshire Western Coroner Area 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 13 February 2018 I commenced an investigation into the death of Edward Arthur AKROYD aged 4 Days. The investigation concluded at the end of the inquest on 13 December 2021. The Narrative conclusion of the inquest was that: Edward Arthur Akroyd was born at Calderdale Royal Hospital at 19.44 hours on 13th January 2018 by forceps delivery. It is likely that if during labour his mother s elevated blood pressure had been more closely monitored and treated and closer monitoring and correct interpretation of CTG tracing during labour had been made , it is likely that steps would have been taken to ensure his earlier delivery. If this had occurred, it is likely that his death at 20.45 hours on the 17th January 2018 at Leeds General Infirmary from severe Hypoxic Ischaemic Encephalopathy would have been prevented 4 CIRCUMSTANCES OF THE DEATH In 2018 Edwards mother was booked to deliver her first child at the midwifery led Huddersfield Birthing Centre. At 7.00am on the morning of the 13th January 2018 , she attended the Centre after developing contractions. She was later transferred at 17.15 hours to Calderdale Royal Hospital following a diagnosis of Pre-elampsia with symptoms of elevated maternal hypertension. She was placed under the care of both a midwife and registrar doctor who both undertook various reviews and assessments in the ensuing hours. At 19.20 hours, the attendant registrar detected abnormalities in the CTG tracing and determined that the delivery should be expedited and directed that Mrs Akroyd should undergo a forceps delivery. Edward was delivered at 19.44 hours on 13th January 2018, he was in a critical condition . Following initial review and treatment at Calderdale Royal Hospital, Edward was transferred to Leeds General Infirmary for further intensive review and treatment. Despite this provision , his condition continued to give rise for concern and did not improve . Sadly his death was confirmed at 20.45 hours on 17th January 2018 at Leeds General Infirmary 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. Regulation 28 – After Inquest Document Template Updated 30/07/2021 The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) please see attached sheet 6 ACTION SHOULD BE TAKEN In my opinion 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 April 28, 2022. 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. COPIES and PUBLICATION 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons « and Minton morrill solicitors» I have also sent it to who may find it useful or of interest. 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 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 by the Chief Coroner. 9 Dated: 04/03/2022 Mary T. BURKE HM Assistant Coroner for West Yorkshire Western Coroner Area Regulation 28 – After Inquest Document Template Updated 30/07/2021 1. Whilst Mrs Akroyd was being cared for at Huddersfield Birthing Centre, her blood pressure was not checked and fresh eyes review was not undertaken at the appropriate time in accordance with the trust guidance. I am concerned that if this were to reoccur there is a real risk of missed opportunities to identify significant changes which could impact upon both the mother and unborn baby’s wellbeing. 2. At the time of transfer of care between midwives, following arrival at Calderdale Royal hospital, the attendant midwife did not enter a complete handover record in Mrs Akroyds notes, as she understood that it was the duty of the receiving midwife to make a record within the notes. At the inquest, the same midwife who continues to practise, gave evidence that she remained of the view that that was trust policy. The lack of entry in the notes led to confusion and a lack of clarity of previously prescribed medication I heard evidence at the inquest, that the practise undertaken by the midwife was not trust policy at the time nor subsequently and it is the role of the midwife handing over care to complete a medical record within the patients notes . I am concerned that if complete and effective medical notes and records are not made, this may impact on decision making and treatment and in turn to the wellbeing of expectant mothers and their unborn child. 3. After a diagnosis of pre-eclampsia was made at Huddersfield birthing centre and Prior to transfer, various samples were obtained and sent for laboratory analysis, some of the results were received at Huddersfield Birthing Centre and phoned through to the labour ward at Calderdale Royal Hospital. From the evidence presented, the results were not passed to Mrs Akroyds attendant midwife or treating registrar. The subsequent internal review did not appear to investigate and determine the reason why this did not occur. I am concerned that if this were to reoccur, important information may not be provided which could pose a risk to the wellbeing of an expectant mother and or their unborn child In evidence, Mrs Akroyd attendant midwife at Calderdale Royal Hospital did not appear to acknowledge that there was a need for her to continue to undertake regular monitoring of Mrs Akroyds Blood pressure in light of earlier readings and to escalate to either a doctor or labour ward co-ordinator, I am concerned that if similar circumstances were to re-occur, this poses a risk to the wellbeing of expectant mother and her unborn child. The same midwife also in evidence appeared to state that there was no need to review Mrs Akroyds earlier records as a verbal handover had been made, once again I am concerned that if this were to reoccur, it may pose a risk to the wellbeing to expectant mother and child. 4. 5. The registrar who was seized of Mrs Akroyds care following transfer to Calderdale Royal hospital, in evidence stated that both at the time and also from the position of hindsight, considered Mrs Akroyds blood pressure both prior to and post transfer was only marginally elevated and he based his treatment plan on this view. I heard evidence from various consultants, that Mrs Akroyds blood pressure was significantly elevated, which required urgent treatment and careful review. I am concerned that if similar circumstances were to reoccur, and the same clinician were to hold similar views this may pose a risk to the wellbeing of the expectant mother and unborn child. 6. The same registrar in evidence stated that he was not aware of the recommended treatment for elevated blood pressure at this stage of labour and that he had recognised that Mrs Akroyd had pre-eclampsia and that he understood that the appropriate treatment of pre-eclampsia was the delivery of the baby. I am concerned that if the same facts were to reoccur, and the same registrar were to adopt the same treatment plan within similar time scales, it may present a risk to the wellbeing of the expectant mother and her unborn child. 7. The same registrar in evidence stated that it was his view at the time and also from the position of hindsight, that the ctg trace showed no significant cause for concern until shortly before he made the decision that Mrs Akroyd Should undergo a forceps delivery. I heard evidence from a number of consultants that the ctg trace from shortly after its commencement was showing non reassuring signs which should together with other facts have resulted in an earlier delivery of Edward and if this had occurred it is likely he would have survived. I am concerned that if the same facts were to reoccur, and a similar interpretation of a ctg trace was to be made, it poses a risk to the expectant mother and her unborn child. 8. The same registrar in evidence stated that at the time he initially assessed Mrs Akroyd he expected the attendant midwife to provide to him a full verbal update and that there was no necessity for him to have undertaken a review of Mrs Akroyds Medical notes and records. The attendant midwife did not provide a comprehensive summary of Mrs Akroyds medical notes and records. I am concerned that if the same circumstances were to reoccur, there presents a risk to the expectant mother and unborn child. 9. The same registrar stated in evidence that he was aware that samples had been taken at Huddersfield Birthing Centre but didn’t think there was a need to obtain the results to assist in determining an appropriate treatment plan. I am concerned that if similar circumstances were to reoccur it may pose a risk to the wellbeing of the expectant mother and their unborn child. 10. From the evidence presented, and in accordance with trust guidelines, a second midwife should have undertaken a fresh pair of eyes review at 18.40 hours. this did not occur. I understand that such guidelines are put in place so as to ensure that key features are not missed and appropriate treatment plans are put in place. I am concerned that if such reviews do not occur it presents a risk to the wellbeing of expectant mothers and their unborn child
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.
5th May 2022
VIA EMAIL
Ms Mary Burke
HM Assistant Coroner
West Yorkshire- Western Division
City Courts
The Tyrls
Bradford
BD1 1LA
Dear Ms Burke,
REGULATION 28: RESPONSE TO REPORT TO PREVENT FUTURE DEATHS ARISING FROM
THE DEATH OF EDWARD ARTHUR AKROYD
Thank you for your letter dated 4th March 2021 enclosing a Regulation 28 report following your
investigation into the death of Edward Arthur Akroyd.
I am sorry to note that evidence raised a number of concerns and hope that the responses below
will provide you with reassurance of the steps already taken by the Trust to improve patient safety
and minim.ise the risk of future deaths. Addressing your concerns individually (and adopting your
numbering):
1
Whilst Mrs Akroyd was being cared for at Huddersfield Birthing Centre, her blood
pressure was not checked, and fresh eyes review was not undertaken at the
appropriate time in accordance with the trust guidance. I am concerned that if this
were to reoccur there is a real risk of missed opportunities to identify significant
changes which could impact upon both the mother and unborn baby’s wellbeing.
There are two issues here, although the concern with both is actions not being taken in
accordance with timings in Guidance. It is important to say that care in labour should be a
holistic process and that here are times when one aspect of care may take precedence over
another even if that means the timings in guidelines are not strictly followed.
The first issue relates to checking maternal blood pressure. The Trust’s Guidelines for both
the latent phase of labour and normal birth in place at the time state, as now, that maternal
blood pressure should be recorded at least four hourly. This is in line with NICE Guidance,
last updated in 2014.
The first maternal observations, including blood pressure, were taken at 07.40, the next
would be by 11.40 and the one after that by 15.40. In fact, the next set of observations were
taken at 10.57, some 43 minutes earlier than the end of the 4 hour window. That would mean
the next observations would be re-timed to before 14.57.
At 14.46 the birthing pool was being filled at Mrs Akroyd’s request and between 15.00 and
15.58 various steps in urinary care were being undertaken. Other clinical care was therefore
being given within the time period in which maternal observations, including blood pressure
should have been repeated under the Guidelines. Urinary care is an important part of the
holistic care of the mother. There is not always time to do everything all at once.
The observations, including blood pressure, were in fact repeated at 16.05. Although this was
just over 1 hour later than the end of the 4 hour window from the previous observations, it
was only 25 minutes later than it would have been if the previous observations had not been
done early. The blood pressure reading obtained was raised for the first time. The evidence
at the inquest was that it could not be said the blood pressure would have been raised if
taken earlier, and it can rise quickly. Therefore, in this case, had the blood pressure been
taken in line with the guidance the first raised blood pressure may well not have been
identified until 3 hours later than it in fact was.
The above illustrates the point that, while Guidance is based on best evidence of appropriate
time intervals, the ability of observations to detect issues is somewhat arbitrary.
The second issue is the fresh eyes review. The Trust’s Maternity Services regularly review
and update local guidelines.
The service has also developed a Standard Operating Procedure for Fresh Eyes review in
Labour in the Birth Centre. The SOP states: for women in labour the clinical review including
fresh eyes is to be performed at HOURLY intervals or sooner if there are identified concerns
or until the second stage of labour is identified.
In terms of disseminating guidance, refreshing the knowledge of staff and monitoring
compliance: All new and revised guidelines are placed on the Trust’s intranet and are
available at any time electronically. The weekly Maternity Risk Management Newsletter will
have a notice about new or revised guidelines. The compulsory annual Obstetric Emergency
Training Day contains reminders about these guidelines.
All Midwives also have compulsory annual training on monitoring CTGs, which also covers
the guidelines on monitoring the mother.
The implementation is monitored through the Trust’s system of weekly Maternity Governance
Meetings. Those meetings include senior management and clinical staff and review any
cases falling within a range of incidents. All cases involving the relevant criteria are reviewed
irrespective of whether harm actually occurred to mother or baby. Part of that review is
consideration of whether applicable guidance, including monitoring, was followed. If any
issues are identified there is a process to feedback to individual staff members and more
widely across the maternity services.
2
At the time of transfer of care between midwives, following arrival at Calderdale Royal
hospital, the attendant midwife did not enter a complete handover record in Mrs
Akroyds notes, as she understood that it was the duty of the receiving midwife to make
a record within the notes. At the inquest, the same midwife who continues to practise,
gave evidence that she remained of the view that that was trust policy.
The lack of entry in the notes led to confusion and a lack of clarity of previously
prescribed medication I heard evidence at the inquest, that the practise undertaken by
the midwife was not trust policy at the time nor subsequently and it is the role of the
midwife handing over care to complete a medical record within the patients notes.
I am concerned that if complete and effective medical notes and records are not made,
this may impact on decision making and treatment and in turn to the wellbeing of
expectant mothers and their unborn child.
This process remains the same. It is the responsibility of the transferring midwife to complete
a documented structured (SBAR) handover in the clinical records, as well as giving a verbal
handover. Since 2018 the Trust has done a lot of work within the Maternity Service and more
widely on SBAR handovers, including what to document; where to put the information in the
computer records and how to access the information. There is now a specific designated part
of the computer records for the recording of the information.
Insofar as this concern relates to a particular Midwife the Trust can confirm that the Head of
Midwifery met with the midwife concerned who has reflected on her understanding of the
necessity for a documented handover of care along with a verbal handover of care. The Head
of Midwifery reiterated that the guidance in this area has never changed and it has always
been a requirement that the handover of care is documented by the midwife handing over
care. The midwife has reflected that it would be useful for her to refresh her training in the
use of the Guardian Intrapartum element of the maternity electronic patient record. For
personal reasons the midwife in question has not yet undertaken this training but will be
supported to do so as soon as she is in a position to do so.
3
After a diagnosis of pre-eclampsia was made at Huddersfield birthing centre and Prior
to transfer, various samples were obtained and sent for laboratory analysis, some of
the results were received at Huddersfield Birthing Centre and phoned through to the
labour ward at Calderdale Royal Hospital.
From the evidence presented, the results were not passed to Mrs Akroyds attendant
midwife or treating registrar. The subsequent internal review did not appear to
investigate and determine the reason why this did not occur.
I am concerned that if this were to reoccur, important information may not be provided
which could pose a risk to the wellbeing of an expectant mother and or their unborn
child.
It should be noted that there was no diagnosis of pre-eclampsia at the Huddersfield Birthing
Centre. High blood pressure was recognised. Nevertheless, the results of the blood tests
should have been accurately passed on. It was not felt possible to pursue the matter in the
4
5
Trust’s SI investigation because it was not possible to identify the person to whom the
information was said to have been given at Calderdale Royal Hospital.
The computer system for reporting results has changed since 2018. As soon as results are
put on to the laboratory computer system those results are pulled through to the primary
patient record and can then be seen on the “home” screen of the Trust wide system. Any
doctor or midwife can therefore check on the blood test results, including remote access, for
example, an on call consultant accessing the system from home. This means there is no
need for the results to be phoned through or passed on verbally.
In evidence, Mrs Akroyd attendant midwife at Calderdale Royal Hospital did not appear
to acknowledge that there was a need for her to continue to undertake regular
monitoring of Mrs Akroyds Blood pressure in light of earlier readings and to escalate
to either a doctor or labour ward co-ordinator, I am concerned that if similar
circumstances were to re-occur, this poses a risk to the wellbeing of expectant mother
and her unborn child.
The same midwife also in evidence appeared to state that there was no need to review
Mrs Akroyds earlier records as a verbal handover had been made, once again I am
concerned that if this were to reoccur, it may pose a risk to the wellbeing to expectant
mother and child.
The Head of Midwifery met with the midwife concerned and is assured that she has reflected
on this case. The Head of Midwifery also commissioned a review of the role specific safety
training undertaken by the midwife since this incident occurred and can confirm that the
midwife has completed the fetal wellbeing training package (K2) annually, has completed the
Obstetric Emergency training (PROMPT) annually and has also completed the Maternal
Advanced Illness Management training programme in 2020. The Head of Midwifery also
commissioned a review of high risk cases that the midwife has provided care for since this
incident and is assured about her practice and that the midwife has learnt from this incident.
The Trust has no concerns about this midwife.
The registrar who was seized of Mrs Akroyds care following transfer to Calderdale
Royal hospital, in evidence stated that both at the time and also from the position of
hindsight, considered Mrs Akroyds blood pressure both prior to and post transfer was
only marginally elevated and he based his treatment plan on this view. I heard
evidence from various consultants, that Mrs Akroyds blood pressure was significantly
elevated, which required urgent treatment and careful review. I am concerned that if
similar circumstances were to reoccur, and the same clinician were to hold similar
views this may pose a risk to the wellbeing of the expectant mother and unborn child.
Concerns 5 to 9 relate to the same Registrar and so the response to this concern in relation
to the doctor’s reflection and practice should also be read as applying to the responses to
concerns 6 to 9, with the addition of specific relevant information.
This was the doctor’s first inquest, and he acknowledges that he found the experience
confusing as well as intimidating to a degree. He was recalling events that had taken place
almost 4 years before and did not intend to give the impression that his practice has not
changed.
He has reflected on this case with his clinical supervisors and with a number of consultant
colleagues. He has had annual appraisals and undergone the vigorous process of
assessment and was awarded a CESR certificate and recognised on the specialist register
by the GMC on 30 November 2020. Since his involvement in Mrs Akroyd’s care, he has since
progressed to a substantive Consultant post at the Trust.
He has safely practised obstetrics for the last 4 years since this event without any concerns
or adverse outcomes. The Trust have reviewed a number of cases relating to his
management of women with preeclampsia in labour as well as cases with abnormal CTG
and no concerns have been identified. The Trust are satisfied with his competency and
current practice.
In relation to the management of blood pressure and pre-eclampsia the doctor is aware of
current guidelines for the management of patients with severe pre-eclampsia and, as a
Consultant in Calderdale Royal Hospital, has treated patients with pre-eclampsia without any
concerns with his management. He attended the Managing Obstetric Emergencies and
Trauma (MOET) course in 2017 which provides training and awareness around recognition,
resuscitation and treatment of emergencies in patients with the altered physiology and
anatomy of pregnancy. Since them, he has attended annual Practical Obstetric Multi-
Professional Training (PROMPT) Training organised by the Trust since joining the Trust and
is competent in the management of pre-eclampsia.
The same registrar in evidence stated that he was not aware of the recommended
treatment for elevated blood pressure at this stage of labour and that he had
recognised that Mrs Akroyd had pre-eclampsia and that he understood that the
appropriate treatment of pre-eclampsia was the delivery of the baby. I am concerned
that if the same facts were to reoccur, and the same registrar were to adopt the same
treatment plan within similar time scales, it may present a risk to the wellbeing of the
expectant mother and her unborn child.
Please see the response to concern 5 above.
The same registrar in evidence stated that it was his view at the time and also from the
position of hindsight, that the CTG trace showed no significant cause for concern until
shortly before he made the decision that Mrs Akroyd Should undergo a forceps
delivery. I heard evidence from a number of consultants that the CTG trace from
shortly after its commencement was showing non reassuring signs which should
together with other facts have resulted in an earlier delivery of Edward and if this had
occurred it is likely he would have survived.
I am concerned that if the same facts were to reoccur, and a similar interpretation of a
CTG trace was to be made, it poses a risk to the expectant mother and her unborn
child.
Please see the response to concern 5 above.
6
7
8
9
10
Additionally, the doctor has completed appropriate CTG courses over the last 4 years and
has remained up to date with his K2-CTG training. He has also attended advanced CTG
interpretation courses to improve his understanding of CTG interpretation and acumen.
The same registrar in evidence stated that at the time he initially assessed Mrs Akroyd
he expected the attendant midwife to provide to him a full verbal update and that there
was no necessity for him to have undertaken a review of Mrs Akroyds Medical notes
and records. The attendant midwife did not provide a comprehensive summary of Mrs
Akroyds medical notes and records. I am concerned that if the same circumstances
were to reoccur, there presents a risk to the expectant mother and unborn child.
Please see the response to concern 5 above.
Additionally, the doctor has attended communication skills courses. He has made changes
to his practice adopting a more pro-active approach to reviewing and checking information
when taking handovers.
The same registrar stated in evidence that he was aware that samples had been taken
at Huddersfield Birthing Centre but didn’t think there was a need to obtain the results
to assist in determining an appropriate treatment plan. I am concerned that if similar
circumstances were to reoccur it may pose a risk to the wellbeing of the expectant
mother and their unborn child.
Please see the responses to concerns 5 and 8 above and also the change in the way in which
tests results are now made available, in the response to concern 3.
From the evidence presented, and in accordance with trust guidelines, a second
midwife should have undertaken a fresh pair of eyes review at 18.40 hours. this did
not occur. I understand that such guidelines are put in place so as to ensure that key
features are not missed and appropriate treatment plans are put in place. I am
concerned that if such reviews do not occur it presents a risk to the wellbeing of
expectant mothers and their unborn child.
A fresh eyes assessment should be undertaken by a second person qualified to assess the
CTG. This does not have to be a midwife, an Obstetrician at registrar level would be regarded
as suitably qualified to undertake a fresh eyes assessment. In this case the Registrar
reviewed Mrs Akroyd at 18.53. This was however 13 minutes later than the best practice of
60 minutes.
For the reasons given in response to concern 4 above the Head of Midwifery is satisfied the
midwife concerned is requesting fresh eyes reviews appropriately.
I do hope that I have addressed your concerns and that I have reassured you that the steps taken
by the Trust will prevent the recurrence of a similar set of circumstances as those in the case of
Edward Akroyd.
Should you have any further questions arising from the contents of this letter, please do not hesitate
to contact me. I am again sorry that your investigation into this death caused you such significant
concern to issue a Regulation 28 Report and hope that you are now reassured.
Yours Sincerely
Deputy Chief Executive
Calderdale and Huddersfield NHS Foundation Trust
[5th May 2022]
5th May 2022 VIA EMAIL Ms Mary Burke HM Assistant Coroner West Yorkshire- Western Division City Courts The Tyrls Bradford BD1 1LA Dear Ms Burke, Representations as to Publication of this Response in accordance with the Chief Coroners Revised Guidance (No.5) Reports to Prevent Future Deaths Further to our letter of response dated 27 April 2022 and in accordance with the Chief Coroners Revised Guidance (No.5) Reports to Prevent Future Deaths, the Trust seek to make repreparations as to the publication of your concerns and the Trusts subsequent response. As concerns and responses relating to 2, 4, 5, 6, 7, 8 ,9 and 10 refer to individual clinical staff, the Trust feel at least in part, detailed steps taken by and in relation to those individual members of staff should be redacted as the concerns, coupled with the evidence at the inquest, would easy identify the staff involved. The Trust respectfully request that insofar as the concerns and responses relate to individuals who could be identified they should not be published. This contains very specific and personal information and publication, and identification could be very damaging to the individuals in circumstances where the responses set out the measures they have taken in terms of reflection and education. Notwithstanding, the Trust is satisfied as to competence or, in one case, is facilitating further training as the member of staff returns to work. In the circumstances, the Trust would request that Concern 2 be summarised to say it relates to the process of handover and only the first paragraph of the response is published. With regards to concerns and responses relating to 4, 5, 6, 7, 8 and 9, the Trust requests that this not be published. The Trust further requests that the second paragraph of the Response to Concern 10 is also not published. We hope you understand our request and will consider the same. Yours Sincerely Deputy Chief Executive Calderdale and Huddersfield NHS Foundation Trust [5th May 2022]
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