Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0103, written 6 Apr 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Apr 2022 |
|---|---|
| Reference | 2022-0103 |
| Deceased | Oliver Lindsay |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Child Death (from 2015) · Hospital Death (Clinical Procedures and medical management) related deaths |
| 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Chief Coroner 1 CORONER I am Alison Mutch, Senior Coroner, for the Coroner Area of Greater Manchester South 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 2nd March 2021 I commenced an investigation into the death of Oliver Christopher Lindsay. The investigation concluded on the 2nd February 2022 and the conclusion was one of narrative: Died of the recognised complications of an unexpected placental abruption. The medical cause of death was 1a Severe Hypoxic Ischaemic Encephalopathy 1b Placental Abruption on a background of fetal growth restriction 4 CIRCUMSTANCES OF THE DEATH On 4th September 2020 Oliver Christopher Lindsay was identified as having fetal growth restriction following a scan at 38 + 5 weeks. In the early hours of 6th September 2020 whilst at home his mother had a sudden and unexpected placental abruption. Oliver was born at home very quickly with the support of the ambulance service. He was immediately given advanced paediatric life support and was transferred to Stepping Hill Hospital. It was identified that he had suffered a severe hypoxic brain injury as a consequence of the placental abruption. He was transferred to Royal Oldham Hospital where he died on 12th September 2020. 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. 1 The MATTERS OF CONCERN are as follows. – 1. At his mother’s midwife check-up, it was identified that Oliver may have fetal growth restriction and that a scan was urgently required. A referral was made to the acute trust. However scanning capacity issues meant that there was a delay in an appointment being offered. Oliver’s parents were very concerned and felt they had no choice but to pay to have a private scan which did confirm fetal growth restriction and resulted in his mother attending the acute trust to be seen. The inquest heard evidence that there were capacity issues in relation to growth scans nationally particularly after a bank holiday or a weekend. 2. The inquest heard evidence from a number of obstetricians about the very significant risks fetal growth restriction presented to the health of a baby. There was clear evidence that the risks of fetal growth restriction were not widely understood outside experienced obstetric professionals and that greater understanding and clarity of the risks was important in helping all those involved. This was particularly true in relation to parents faced with a sudden change at a difficult time. It was suggested during the inquest that as part of the Saving Babies bundle a FAQ sheet should be developed for parents which set out what fetal growth restriction is ; the risks it presented to a baby at various stages of a pregnancy and the national guidance to reduce risk. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe 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 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 namely, The Next of Kin, Stepping Hill Hospital, Royal Oldham Hospital and North West Ambulance Service who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. 2 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 Ms Alison Mutch HM Senior Coroner HM Coroner’s Court Manchester South 3
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.
From James Morris MP Parliamentary Under Secretary of State for Primary Care and Patient Safety 39 Victoria Street London SW1H 0EU 29th July 2022 Our Ref: PFD - 1401273 Alison Mutch Senior Coroner Coroner's Court 1 Mount Tabor Street Stockport SK1 3AG Dear Ms Mutch, Thank you for your letter of 6 April 2022 about the death of Oliver Lindsay. I am replying as Minister with responsibility for Primary Care and Patient Safety. Firstly, I would like to say how deeply sorry I was to read the circumstances of Oliver Lindsey’s death and I offer my most heartfelt condolences to his family. We must do all we can to ensure such failings in care do not occur again. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention. In preparing this response, my officials made enquiries with NHS England and NHS Improvement, as well as the Care Quality Commission. You may wish to know that since this incident occurred, NHSEI (in collaboration with national maternity and neonatal partner organisations including Royal Colleges, Neonatal Critical Care CRG, HSIB, NMC and NHS Resolution) have published on 17th December 2020 a framework to address known variation in training and competency assessment to ensure that training to address significant areas of harm are included as minimum core requirements for every maternity and neonatal service – this is the Core Competency Framework1. There are 8 priority areas, which are also are set out in Safety Action 8 of the Maternity Incentive Scheme2. Included in the core competency modules is training for maternity staff on implementation of the Saving Babies Lives Care Bundle Version 2, which includes monitoring fetal growth restriction, with links to the national e-learning for health training modules. Full implementation of the Care bundle is expected of all maternity care providers, and this is monitored via Safety Action 6 of the Maternity Incentive Scheme. 1 https://www.england.nhs.uk/wp-content/uploads/2020/12/core-competency-framework.pdf 2 https://view.officeapps.live.com/op/view.aspx?src=https%3A%2F%2Fresolution.nhs.uk%2Fwp- content%2Fuploads%2F2020%2F02%2FMaternity-Incentive-Scheme-year-three- guidance.docx&wdOrigin=BROWSELINK Element 2 of the Saving Babies Lives’ Care Bundle Version 2: Risk assessment and management of babies at risk of fetal growth restriction, seeks to identify all babies at risk. The element recognises that there is a range of expert opinions on some interventions and allows flexibility in the choice of pathways. It therefore advocates personalised, safe care and choice for all women. My officials have informed me that NHSEI are in the process of updating the Care Bundle and have service user representation on their related Steering Group. It is expected that the maternity systems should be ready to implement this on publication later this year. As part of the review the intention is to update the Care Bundle with the latest evidence based research including RCOG Green Top Guidance for management of Fetal Growth Restriction (FGR) (which is to be published imminently) and information for women and pregnant people which will seek to address the issues raised from your report in relation to risks associated with FGR. With regard to the health and care system, you may wish to know that since the NHS Long Term Plan was published, the NHS has made significant progress in making maternity care safer and more personalised in England. According to the Office for National Statistics, the stillbirth rate in 2020 has reduced to 3.8 per 1000 births, and the neonatal mortality rate, for births at 24 weeks gestation and above, has reduced to 1.3 per 1000 live births. This is ahead of our 20% reduction target from 2010 levels, at 25.2% and 36% respectively. This has been achieved in large part through implementation of the initiatives set out in the Long Term Plan, including rollout of the Saving Babies’ Lives Care Bundle (including new pre- term birth clinics), providing continuity of carer, and investment in additional neonatal nurses. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely, JAMES MORRIS MP PARLIAMENTARY UNDER SECRETARY OF STATE FOR PRIMARY CARE AND PATIENT SAFETY
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