Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0287, written 21 Nov 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 Nov 2022 |
|---|---|
| Reference | 2022-0287 |
| Deceased | Quinn Parker |
| Coroner | Elizabeth Didcock |
| Coroner area | Nottingham and Nottinghamshire |
| Category | Child Death (from 2015) |
| Organisation named | Nottingham University Hospitals NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. The Chief Executive Nottingham University Hospitals NHS Trust (‘The Trust’) 1 CORONER I am Dr Elizabeth Didcock, Assistant Coroner, for the coroner area of Nottinghamshire 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 the 19th July 2021, I commenced an investigation into the death of Quinn Lias Parker, born on the 14th July 2021, who died on 16th July 2021. The investigation continues and the case will come to Inquest in 2022, dates to be confirmed. 4 CIRCUMSTANCES OF THE DEATH Quinn was born in a very poor condition, and it was sadly clear within 1- 2 hours of his birth, that he remained extremely unwell, and there was a high probability that he would not survive. There were concerns raised by his parents at this early point, regarding the care provided by The Trust, in relation to the management of Emmie, his mother, in late pregnancy, and regarding the timing of Quinn’s delivery. In the event of Quinn’s death, it would therefore require referral to the coroner, and thought needed to be given to the preservation of the placenta, to ensure that it was available for examination as part of the Paediatric post mortem. In this case, the placenta was cut into/dissected after Quinn’s death without discussion with the Coroner. This has affected the ability of the Paediatric Pathologist instructed by the Coroner, to determine the likely cause of Emmie’s antepartum haemorrhage. Whilst the medical cause of Quinn’s death will be explored in full at the Inquest, it is likely that the antepartum haemorrhage, and the underlying pathology causing it, is directly related to Quinn’s death. It is not clear to me exactly how the placenta was cut into after Quinn’s death without discussion with the Coroner - this will be fully explored at the Inquest, but what is clear is that the outcome has been highly detrimental to the independent investigation by the Coroner and other agencies investigating the circumstances of this case. This death follows a number of similar early neonatal deaths in Nottingham, where the placenta has not been retained, and therefore key information regarding placental pathology has been lost. 5 CORONER’S CONCERNS During the course of the investigation the evidence revealed matters giving rise to concern. If the coroner is inhibited from being in a position to confirm the cause of 1 death of a baby, 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. The placenta, a key organ required for a full paediatric post mortem in an early neonatal death, has been interfered with such that the Paediatric Pathologist, is limited in his conclusion as to the likely cause of death. In some ways the placenta is akin to an organ for the purposes of a paediatric post mortem- Loss of an organ at any post mortem examination, may well undermine the ability of the pathologist to carry out a full and proper examination. Decisions surrounding interference with, or disposal of, the placenta should be made in a careful and considered manner, with thought given to an early discussion with the coroner as would happen if organ donation is being considered. This did not happen in this case. 2. Unfortunately, there have been a number of cases in Nottingham where the death of a baby shortly after the birth was anticipated, but the placenta was disposed of and/or interfered with prior to the death being reported to the coroner. This undermines the coronial investigation resulting in limited findings and therefore limited conclusions at inquest. This will likely lead to a lack of learning from such deaths, and therefore a risk that similar deaths will occur in the future. It may also deprive the parents of significant information when considering whether future pregnancies may be at greater risk with the consequent need for appropriate management and planning. 3. The Nottinghamshire Coronial service has to date worked collaboratively with all local Trusts, but particularly with NUH NHS Trust, to ensure key staff understand the importance of retaining the placenta in an early neonatal death. This has not led to the actions necessary to achieve a full and proper examination of the placenta in repeated paediatric post mortems in this jurisdiction. 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 the 16th December 2021. 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: parents of Quinn Parker The Healthcare Safety Investigation Branch The Care Quality Commission The Nottingham and Nottinghamshire Clinical Commissioning Group 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 2 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 21st October 2021 Dr E A Didcock 3
3 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.
Please ask for the Medical Director’s Personal Assistant Our Ref: KG/JF 9th December 2021 PRIVATE & CONFIDENTIAL Dr E A Didcock Assistant Coroner (Nottinghamshire) Dear Dr Didcock Medical Director’s Office 3rd Floor, Trust Headquarters City Hospital Campus Hucknall Road Nottingham NG5 1PB www.nuh.nhs.uk REGULATION 28 REPORT TO PREVENT FUTURE DEATHS: QUINN LIAS PARKER I am the Medical Director at Nottingham University Hospitals NHS Trust and I write in response to the Report to Prevent Future Deaths issued on the 21st October 2021 in relation to the death of Quinn Lias Parker. I have reviewed the Preventing Future Deaths report with all the clinical teams who have a role related to retention and examination of a placenta and I respond to the Matters of Concern following a detailed discussion of this case. I have attached to this response the current NUH guideline that relates to the retention and examination of a placenta following birth. The guideline describes that at every birth a decision is made to either retain the placenta for 48 hours in a local fridge during the initial period of the baby’s life or to send this directly to the pathology laboratory. It should be noted that the placenta is regarded as an organ of the mother, not the baby, and so is stored with reference to the mother’s details. If the baby is deemed well at 48 hours the placenta is disposed of in a safe and appropriate way. The guideline describes a number of situations in which the placenta may be sent directly to the pathology laboratory for fixation and examination. One of these situations is where the baby is admitted directly to the Neonatal Intensive Care Unit immediately after delivery. Such was the situation for Quinn and the placenta was sent directly to pathology. The laboratory undertakes a fixation process for the placenta tissue that they receive and this was duly undertaken. The time taken to ‘fix’ tissue is variable and depends on a number of factors but typically takes in the range of 48-72 hours before the placenta is ready for examination. Once ‘fixed’ and when ready for examination a standard approach is used to dissect the placenta and gain material for histological examination. The placenta in this case was dissected according to standard techniques. Following dissection and prior to the pathologist’s examination the lab was informed of Quinn’s sad death and the process was stopped pending instruction from HM Coroner as per laboratory standard operating procedures. It is the case that Quinn had actually died prior to the dissection of the placenta commencing and that had the laboratory been informed of the death earlier the examination would not have been started. As above, the placenta is one of the maternal organs and not an organ of the baby and so is linked to the mother’s records and not those of the baby. The laboratory only become aware of the baby’s death when informed directly by the clinical or medical examiner team. It remains unclear to the NUH pathologists how the standard dissection of the placenta that took place in this case has affected the conclusions of the Paediatric Pathologist. For this Report to be fully understood further clarification on this would be very helpful and this has been sought with the support of HM Coroner. In response to this Report the Trust will develop a standard procedure such that in the case of any neonatal death within 48 hours of birth the medical examiner team will inform the pathology laboratory of this at the very earliest opportunity. Once further information is gained in relation to the placental examination the Pathology Department will review whether there needs to be any adaptation to current examination processes. Yours sincerely Medical Director GMC Number 3261947 Enc
Please ask for the Medical Director’s Personal Assistant Our Ref: KG/JF 11th January 2022 PRIVATE & CONFIDENTIAL Dr Elizabeth Didcock Assistant Coroner, Nottinghamshire Medical Director’s Office 3rd Floor, Trust Headquarters City Hospital Campus Hucknall Road Nottingham NG5 1PB www.nuh.nhs.uk Dear Dr Didcock email of 3rd December which I I write in response to your email of the 9th December and have discussed with has highlighted three actions that and also the clinical teams. could have altered the pathological understanding in this case and I would like to respond to each in turn: 1. If the clinical team feel at the time there is placental pathology they should highlight this on their request form The clinical team who would request placental pathology have been reminded to highlight this on the request form. There may, however, be times when that request is not immediately apparent at the time of birth and as in the case of Quinn Parker, this may be requested at a later date. 2. The midwife sending the placenta should examine it and not take the word of another midwife The Director of Midwifery has agreed to remind all midwives about their responsibility to examine placentas according to the guideline prior to sending to pathology and not delegate this task to others. 3. If the BMS noted a vessel in the membrane as in this case, it should be documented as to whether it was intact or ruptured I have attached a new proforma that has been introduced since this case for the BMS to complete at the time of the placenta preparation to ensure that information such as this is captured. I hope that these actions, together with my previous response, provide some assurance that the matters experienced in this case will be averted in the future. With kind regards Yours sincerely Medical Director GMC Number 3261947 Enc
Please ask for the Medical Director’s Personal Assistant Our Ref: KG/JF 28 April 2022 PRIVATE & CONFIDENTIAL Dr Elizabeth Didcock Assistant Coroner (Nottinghamshire) Office and Main Court The Council House Old Market Square Nottingham NG1 2DT Dear Dr Didcock I write further to your two questions that have been forwarded on to me in relation to placentas being cut. These were: 1. What are the processes now in place in the Pathology and Maternity Departments that will prevent/reduce the risk of a placenta being cut into after the death of a baby, when a referral to the Coroner has been made/is likely to be made? 2. What are the processes now in place in the Pathology and Maternity Departments that will allow a ‘stop’ and then consideration of a discussion with the Coroner, as to whether examination of the placenta in Histopathology is appropriate if there is concern that a baby is very unwell and may go on to die? It may assist to first be appraised of the background to your request; there are in the region of 8-9000 births a year in the Trust. All of the placentas from those births are kept for 48 hours by the Obstetric Department whilst a decision is made as to whether or not there is any clinical reason to request a pathology review of the placenta. The clinical reasons for sending a placenta to Pathology are set out in an existing policy which includes all still births. In addition, there are around 975 admissions to NICU each year. Some of these are of neonates who were not born at a Trust site and so the Trust will not have had their mother’s placenta in its custody. However in the case of all unexpected NICU admissions who were born at a Trust site their placenta is automatically sent to the Pathology Department for examination. The Trust’s Pathology Laboratory examines in the region of 700 placentas a year. These include all those related to NICU admissions and those where a request has been generated by the Obstetric Department. The number of babies admitted to NICU who die in the neonatal period is in the region of 25 per annum. Many of these deaths do not come under the Coroner’s jurisdiction, although all neonatal deaths are now referred to and scrutinised by the Medical Examiner. At the time of Quinn’s birth, placentas would either be retained by local maternity services for 48 hours and the placenta would be disposed of at the end of that period if mother and baby were deemed well , or, where a baby was admitted to NICU the placenta would be sent directly to Pathology (as it was in Quinn’s case) for fixation and examination. Quinn’s placenta was dissected in under 48 hours from his birth (on the afternoon of 16 July) because of the particular expedition in the case of NICU placentas and the Pathology Laboratory not having been made aware of his sad death earlier that morning. Last year, in the light of your PFD report, an immediate 48 hour stop was put on the dissection of all placentas. However we have since reviewed the proposed processes and the length of that stop has been extended and is now set at 96 hours (ie 4 days) for all placentas that are sent to Pathology. A placenta may be fixed during that period, to prevent its deterioration, but it will not be dissected. Currently, the Medical Examiner informs Pathology of any baby deaths within the first 48 hours. However, the Neonatal Team have also been in discussion with our Head of Patient Safety, the Medical Examiner and Digital Lead to create a digital solution. We propose to use the Trust’s NerveCentre system to notify Pathology of a baby’s death. This will be done through an automatic ‘push’ notification to the Pathology Team to allow them to see that a baby has died. We are in the process of testing the system prior to rolling out training and setting a go live date. The advantage of a ‘push’ notification is that it does not require any additional human intervention to inform Pathology of a death. This along with the longer ‘stop’ period of 4 days will, we hope, ensure that for the majority of relevant deaths in the neo-natal period there will be an opportunity for your office to have further communication with Pathology regarding the examination of the placenta. You have asked what processes are in place to allow for consideration of a discussion with the Coroner, as to whether examination of the placenta in Histopathology is appropriate if there is concern that a baby is very unwell and may go on to die. After consultation with Obstetricians, Neonatologists, Pathologists and Digital Lead, it is the view of the Trust that it is not proportionate nor practically achievable to devise a process that would reliably allow for this given that all of the 975 admissions to NICU each year are, by the very nature of NICU, neonates who are very unwell and may go on to die. The death of a neonate on NICU is not predictable in a way that could reliably allow us to identify the 25 or so neonates who do actually die each year. This is why we have determined that extending the Pathology stop period across the board for all placentas, and having discussions with your office where a death occurs within 96 hours, is a preferable and more realistically achievable approach. In 2021 we examined over 700 placentas and any new process must be workable given the large number of cases that the Pathology Department deal with. We believe that this extended Pathology ‘stop’ period will have a number of benefits whilst not being detrimental to mothers’ or live babies if relevant clinical information might be obtained from placental examination. I also understand that the parents of Quinn have some questions they wish to be answered regarding the pathology processes. I shall be writing to them under separate cover to offer them a meeting with appropriate Trust staff, to deal with this and their wider concerns about the Trust’s communication with them. I do however sincerely apologise that the communication was not as the family wished. We have and will continue to reflect on this as an organisation. Yours sincerely Medical Director GMC Number 3261947
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