Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0185, written 20 Jun 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 Jun 2022 |
|---|---|
| Reference | 2022-0185 |
| Deceased | Adele Massoudi |
| Coroner | Heidi Connor |
| Coroner area | Berkshire |
| Category | Child Death (from 2015) · Community health care and emergency services related deaths |
| Organisation named | Royal Berkshire NHS Foundation Trust |
| 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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: Royal Berkshire NHS Foundation Trust: Chief Executive, 1 CORONER I am HEIDI J CONNOR, Senior Coroner for Berkshire for the coroner area of Berkshire 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 I conducted an inquest into the death of Adele Angel Massoudi at Reading Town Hall on 25th, 26th, 27th May and 10th June 2022 I recorded a conclusion of natural causes contributed to by neglect. 4 CIRCUMSTANCES OF THE DEATH Adele Massoudi was born at 0521 on 26th June 2020, as a planned home birth. She was transferred to the Royal Berkshire Hospital at 0542, and then to the John Radcliffe Hospital in Oxford at 1330 hours. She died there on 2nd July 2020. No autopsy was conducted, and the cause of death was recorded as severe hypoxic ischaemic encephalopathy. I handed down written conclusions in this case. This report summarises my key conclusions and concerns. During the course of the inquest, it became clear that there was significant delay in responding to the presence of meconium during labour. The fetal heart rate was inadequately monitored, even after meconium was seen. The unfolding emergency was not adequately communicated to the family. Transfer to hospital should have taken place much sooner, and Adele should have been born in hospital. The placenta appears to have been destroyed without retaining it for examination. An independent expert advised that, had Adele been transferred to hospital at any point up to and including the actual time of her birth at home, then, with the additional monitoring equipment and neonatal resuscitation options there, it is likely she would have survived. Whilst his view was that she may have suffered some compromise had she survived, that was not a matter relevant to a coroner's inquest. I was concerned to hear the midwife in question give evidence that she believed that she called 999 as soon as she could have. She described lots of things happening at once, and that she saw her role as one of communicating with family and calling for help as needed. She accepted under questioning that it would have been a simple thing to call an ambulance and that she should have called an ambulance on arrival at the family home. In fact, she called the delivery suite, and her colleague, a midwifery support worker, and only then did she dial 999, some 30 minutes after arriving. Regulation 28 – After Inquest Document Template Updated 30/07/2021 Whilst continuous fetal heart rate monitoring is not possible in a home birth setting, the fetal heart rate should have been monitored every five minutes. In the hour before birth, there are only 5 recordings of the fetal heart rate. It was accepted in evidence that monitoring of the fetal heart rate is even more important in the context of meconium, and hence concerns for the baby. There are no recordings of Adele’s heart in the ambulance. The evidence was that the midwifery support worker put the placenta in a plastic carrier bag and brought it to hospital, but there was no trace of it after that. 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. The MATTERS OF CONCERN are as follows: 1. Midwifery Training The hospital’s updated action plan deals with a lot of training and refreshment of training that has taken place since this incident and since the HSIB report. I note in particular that an audit between May 2021 and March 2022 has revealed that, in 12 cases reviewed for women having a home birth with meconium present, 100% of those patients were taken to hospital via emergency ambulance. An escalation flow chart has been added to the home birth standard operating procedure. That has been added to the home birth kit. I am mindful however that transferring a patient to hospital where meconium is seen in a home birth setting was always part of the training. This is not new or particularly complex guidance. At one point in her evidence, the midwife in question said this: I will say, I believe at the time, faced with the clinical situation I was faced with, there were multiple things to be doing at once and [the mother] was having regular contractions. So I was trying to communicate with the family in between the contractions, the checks that we do on the mum and the baby. Again, I can’t perform those while she's having a contraction. So I was waiting for in between those contractions, also setting up my equipment. So I feel that in the moment, time passed very quickly.…. She accepted in her evidence that it was open to her to ask someone else on scene, including a family member, to call for an ambulance. I remain concerned that the response of the key witness appears to be “I did what I could in difficult circumstances, and I had a lot to do”. The situation that the midwife was dealing with must indeed have been very stressful, but it is part of a midwife’s professional training to assess what is the most urgent thing to do first. That is not setting up equipment, waiting for contractions to finish et cetera. It is, in this scenario, to call an ambulance first and then do everything else afterwards. I remain concerned that, even after all the additional training, and having had this awful experience, this message is not coming through loud and clear from the witness evidence. It is difficult to know whether a need for further training exists in relation to this witness, or more systemically. I am concerned that, having experienced this awful tragedy, and going through the HSIB investigation and the inquest process, anything other than full acceptance of the point was offered in evidence. I invite the trust to consider again the training of their midwives and whether the training provided to date is sufficient and safe, and to respond formally and in a Regulation 28 response. 2. Placenta retention In terms of learning from these cases, examination of the placenta, either as part of a formal autopsy, or even without an autopsy, is absolutely vital. It is akin to asking a pathologist to Regulation 28 – After Inquest Document Template Updated 30/07/2021 conduct a post-mortem examination without one of the organs, if the placenta is not retained. I am concerned about the response from the hospital trust on this point. I am told that the guideline for placenta examination is being reviewed and I quote from the statement sent by the Director of Midwifery, dated 6 June 2022: We continue to explore opportunities that may extend placental storage. It does not go far enough simply to state “we are looking into it” at this stage, or that the trust does not have the space to store placentas for longer. I appreciate that the Human Tissue Act and other considerations have to be taken into account. It is not insurmountable, and I believe the trust must now be given a deadline for responding to this concern, in the format of a Regulation 28 Report, in order to ensure that a decision has been made. There are cases where keeping the placenta is clearly required - such as this case - because Adele was born in a poor condition. The practical realities have to be taken into account, and a line drawn as to when placentas should be kept for longer than usual. Currently, placentas in uncomplicated cases are being disposed of daily. I am happy to liaise with the trust in this respect, and to seek the views of a paediatric pathologist, should that assist. I believe this will be a crucial part of death investigation going forward and improving services as a result of any investigations which flow from those deaths. It is important for bereaved families to have the opportunity to investigate all possible reasons for the death of their child, which may also be vital in considering future pregnancies. 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 August 15, 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and Adele’s family 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: 20/06/2022 Regulation 28 – After Inquest Document Template Updated 30/07/2021 HEIDI J CONNOR Senior Coroner for Berkshire for Berkshire Regulation 28 – After Inquest Document Template Updated 30/07/2021
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.
,~1:b1 Royal Berkshire NHS Foundation Trust Executive's Office · Royal Berkshire Hospital Level 4, Main Entrance London Road Reading Berkshire RG1 5AN Private & Confidential Senior Coroner Heidi Connor Berkshire Coroners' Office Readin·g Town Hall Blagrave Street .Reading RG1 1QH By emafl: 29 September 2022 Response to Regulation 28 Report to Prevent Future Deaths Dear Mrs Connor Thank you for granting us additional time to consider and provide our response to your Regulation 28 Report dated 20 June 2022, following the inquest into the death of Adele Massoudi which took place on 25- 27 May and 10 June 2022. I would like to begin by offering my sincerest condolences to the parents of Adeie, In summary, your matters of concern related to two areas; training for staff-who attend homebirths and the retention ·of all placentas for an extended storage period, _including in uncompHcated births. I will address • each matter in turn below . . Midwifery Training · In considering whether the midwifery training provided to date is sufficient and safe, Jhe · Trust commissioned an external midwifery report from a Consultant Midwife, to review the midwifery and maternity_support worker training provided at the Trust. The review took into account a wide variety of resources including training policies and guidelines, lesson plans and training evaluations. It also considered national publications and evidence, as well as conducting interviews with members of maternity practice development, matron teams and the South Central Ambulance Service clinical education team. The following eight recommendations were made for future training provision and the Trust are developing -an action plan to address the recommendations. The proposed actions can be summarised as follows: . 1. Review the maternity Training Needs Analysis [TNAJ document to better reflect training undertaken; The expectations of staff members, educators and managers are clearly detailed within the TNA and inch.,!de the management of non-attendance. This, along with the interviews undertaken, gave· the reviewer a very positive indication of the Trust's commitment to training. To give further quality assurance the TNA is· being reviewed to provide details of the varied ways in which education is delivered. 2. Increase access to accreditecj Resuscitation Council UK [RCUKJ neonatal life support training for midwives delivering community intrapartum care; The Trust have increased funding for an additional 15 places every year with priority spaces peing given to community midwives who provide intrapartum care. r~1:b1 Royal Berkshire · NHS Foundation Trust 3. Introduce extended newborn resuscitation in house for midwives and· maternity support workers delivering community intrapartum care; Skills drills in the community are run by the education team one or twice a month and are attended by midwives and support workers. Enhanced training sessions are 1n development alongside the Trust's resuscitation team, and are being written into the TNA with timeframes on when this must be achie_ved and hpw often staff will need to attend . 4. Make attendance. at PROMPT [Practical Obstetric Multi-Professional Training] training annual for all community staff; The Trust are exploring increasing capacity to enable community staff to attend the PHONE or PROMPT training day annually, whichever is considered the most apprqpriate for multidisciplinary neonatal resuscitation training. 5. Consider strengthening competency assess"!ent within mandatory training; A formal assessment of neonatal resuscitation is now included during induction (delivery of inflation breaths, calling for help and SBAR handover}. The practice development team are .also undertaking training with RBFT resuscitation team to ensure consistency of informal assessments. 6. Undertake a survey of maternity staff working in community settings to assess their training and development needs for intrapartum care; Two surveys are in development for community midwives and maternity support workers to assess their knowledge and· confidence. · 7. Consider offering opportunities for community staff to work in acute site with support, to . enhance their clinical skills and confidence; All new midwives have shifts within the maternity unit as part of their induction. The survey above will also identify whether any further training is indicated for acute site placements to be facilitated, alongside the new homebirth competency/confidence documents which all maternity support workers are required to complete annually with their line managers. 8. Greater MDT collaboration in the design and delivery of training for staff providing intrapartum care in community settings; The neonatal team are currently involved in delivering skill drill training within the unit and discussions are taking place to ensure their involvement in training in community settings. 9. Purchase of additional equipment to support community birth and training. Safety requirements around -community staff keeping drugs at home prevents it being .possible for all community on-call midwives to carry a full range of drugs. The only piece of emergency equipment which is not carried is a suction, and. the Practice Development team are reviewing the use of handheld/portable suckers. A bid has also been made for more divers~ training equipment. Overall, the external Cor-isultant Midwife concluded that the current training offer for community staff providing intrapartum care at the Trust appears sound and effective and no gaps in training topics were identified. ·1n con.clusion she reported that we have many successes in the training we offer, with the s.ervice being open to feedback and actively developing in response to multiple drivers, ·including past incidents. The recommendations made within this review aim tp support the service to clarify and consolidate this _work, and we are committed to delivering accessible and relevant . training on the management of intrapartum emergencies. For additional ·reassurance and alongside this external review, our Chief Nurse commissioned an internal review of the Trust's action plan in response to the Healthcare Safety Investigation Branch (HSIB) investigation into this case. This was undertaken by a senior member of RBFT staff working outside of maternity to provide assurance that lessons were being learnt and improvements made, in light of the recently nationally published Ockenden report, March 2022. This review was presented to the RBFT Urgent r.•1:k1 Royal Berkshire NHS Foundation Trust Care Group Board and concluded that the action plan has been delivered and addresses afl of the recommendations made in the HSIB report. The evidence supported the green RAG (red/amber/green) rating , which is the rating process used by NHS England for the NHS Performance Framework. Placenta Retention Previously, placentas in uncomplicated cases were being disposed of on a daily basis but I can confirm that the Trust have implemented processes to ensure that all placentas are stored for 48 hours from the time of birth. We are advised by the Pathology team that retaining placentas beyond this time would not provide reliable histology findings. · In practical terms, placenta fridges have now been placed in the Delivery Suite and Birth Centre, and homebirth placentas will be placed in the Birth Centre fridge (the Homebirth Operating Procedures have been updated to reflect this). Tutela temperate monitors are operating in the fridges, which provide connected automat_ed monitoring and alerts the clinical areas if there are any concerns with the temperature of the fridge. The Standard Operating Procedure (SOP) for placenta retention will be ratified at the Maternity Clinical Governance Meeting in October 2022 and will go live on 10 October 2022; it provides guidance on which placentas need to be sent to histology for patholog ical examination, as well as storing and retaining all placentas for 48 hours.before disposal in uncomplicated cases. In order to disseminate this information, all of the Trust's Band 7 midwives and Unit Cqordinators will be trained on the new SOP to ensure com.pliance throughout maternity, and .in particular the midwives and maternity support workers. We are also wprking . with Waste Management to ensure that their team are fully aware of the new process, _as they now need to request that a member of the midwifery team attends with them to .ensure that the correct procedures are followed. As an additional assurance, the safety huddle templates on our electronic patient record system will be updated to prompt the team to ask whether any babies have deteriorated or been admitted fron:i other areas in the last 24 hours to the pediatric ward , who are less than 48 hours of age and require ventilation, cooling or neonatal death. This measure will be introduced to ensure that placentas are not erroneously disposed of due to any lack of communication between the-maternity-unit and paediatric ward . I hope thi~ response provides you and the parents of Adele with assurance that the Trust. have taken your concerns for future patients' safety seriously by implementing further actions to ensure that all community midwives · and maternity support workers feel confident in delivering community intrapartum care. In addition , we endorse your view that storing all placentas for at least 48 hours will assist in providing crucial evidence as part of death investigations and therefore will provide an opportunity to improve our services as a result of these actions taken . ' If you require any further information or evidence, please do not hesitate to 9ontact us. Yours sincerely Chief Executive Officer
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