Teegan Barnard

Care Quality Commission 
Citygate 
Gallowgate 
Newcastle upon Tyne 
NE1 4PA 

www.cqc.org.uk 

HM Coroner's Office 

Records Office 
Orchard Street 
Chichester 
West Sussex 
PO19 1DD 

9 March 2023 (resent on 13 March 2023) 

Care Quality Commission 

Dear HM Coroner 

Prevention  of  future  death  report  following  inquest  into  the  death  of  Teegan 
Marie Barnard 

Thank you for sending CQC a copy of the prevention of future death report issued 
following the death of Teegan Marie Barnard. 

CQC has contacted the provider University Hospitals Sussex NHS Foundation Trust 
to request written confirmation and evidence of the action they have taken to date 
following this death and any additional action they intend to take in response to the 
prevention of future death report. 

We note the legal requirement upon the following individuals and organisations to 
respond to your report within 56 days: 

1 
2 
3 
4 
5 

, Chief Executive U. Hospitals Sussex NHS Foundation Trust 

, Medical Director, St Richards Hospital, Chichester 

Chief Executive NHS England 
Chief Executive Health Education England 
Chief Executive CQC 

We are responding as directed. 

Having received your report, the CQC took steps to request information and seek 
assurance from the Trust regarding the concerns within the report. University Sussex 

 
 
 
 
 
 
 
 
 
 
 
  
 
  
  
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Hospital NHS Trust have provided the following documents which CQC have 
reviewed: 

1.  Maternity Improvement Plan - 23.1.23 incl Ockenden (DRAFT) 
2.  CNST MIS_SafetyAction_2023_V9_UHSussex 31012023 
3.  Local Requirements for HSIB Investigations Standard Operating Procedure 
3  Safety Action 8 compliance with multi-professional training 
4.  Integrated UHS Learning from Deaths Annual Report 
4  Summary Hospital - level Mortality Indicator (SHMI) report January 2022-

December 2022. 

5  Quality Mortality Earlier Intervention report 
6  Letter from trust dated 16 February 2023 outlining action taken prevention of 

future death report. 

We have also reviewed the following documents: 

1.) Summing up and conclusion from HM Coroner 
2.) Reg 28 Coroner evidence BARNARD - 6. Full Inquest Additional 1 
3.) Reg 28 Evidence from Coroner BARNARD - 3. Full Inquest Exhibits Medical 

Records. 

4.) Regulation 28 report. 
5.) Reg 28 Evidence form Coroner BARNARD - 1. Full Inquest Statements 

Over the last 18 months, CQC have discharged its regulatory function through 
enhanced monitoring, engagement and inspection of maternity services at each 
main hospital site. 

For ease we will set out all the inspections undertaken in the last 13 months. 

Royal Sussex County Hospital, Brighton 
  28 September - 04 October 2021 
o  Maternity rated inadequate 

Link to report: https://api.cqc.org.uk/public/v1/reports/65b10d86-462c-4f8d-b6de-
907e7356cf15?20211223171918 

  26 and 27 April 2022 (follow up inspection to check compliance against 

warning notice issued following above inspection) 

o  Maternity – inspected but not rated 

Link to report : https://api.cqc.org.uk/public/v1/reports/c55b73a3-3d17-4e31-833e-
59556e80cc95?20220729070335 

Princess Royal Hospital, Haywards Heath 
  28 September – 04 October 2021 
o  Maternity rated inadequate 

Link to report: https://api.cqc.org.uk/public/v1/reports/300ee9ab-0ee2-4035-aa37-
0d5b851b47cc?20211223171918 

  26 and 27 April 2022 

o  Maternity – inspected but not rated (follow up inspection to check 

compliance against warning notice issued following above inspection) 

Link to report: https://api.cqc.org.uk/public/v1/reports/d5a15938-fa30-45b4-bb35-
2eeab72fc3b2?20220729070335 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
   
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
   
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 St Richards Hospital, Chichester 

  28 September – 4 October 2021 

o  Maternity rated requires improvement. 

Link to report: https://api.cqc.org.uk/public/v1/reports/19c41cd3-3d04-4476-b809-
a23a81d695c0?20211223171918 

  26 - 27 April 2022 

o  Maternity – inspected but not rated inspected but not rated (follow up 

inspection to check compliance against warning notice issued following 
above inspection) 

Link to report: https://api.cqc.org.uk/public/v1/reports/81170a7a-3725-4a88-a459-
6eef3de0b385?20220729070335 

Worthing Hospital 

  28 September – 04 October 2021 

o  Maternity rated requires improvement. 

Link to report: https://api.cqc.org.uk/public/v1/reports/9a45b0c0-8332-4635-8bb0-
5e66defae1a6?20211223171918 
  26 and 27 April 2022 

o  Maternity – inspected but not rated (follow up inspection to check 

compliance against warning notice issued following above inspection) 

Link to report:  https://api.cqc.org.uk/public/v1/reports/e8ede713-1a80-40e0-8687-
37b3344c4522?20220729070335 

A Trust wide Well Led inspection was undertaken on 4 and 5 October 2022.The 
report is still undergoing quality assurances processes and will be published on our 
website in due course. 

CQC note the concerns outlined in section 5 of the Regulation 28 report. 

Action CQC intends to take is to agree with the Trust regular engagement meetings 
to monitor and have oversight of the following: 

1.) Request and monitor staff training compliance with emergency life support 

training and the management of deteriorating patients. 

2.) Review audits undertaken by University Sussex Hospital NHS Trust in the 
management of deteriorating patients and compliance against the Trust’s 
policies. 

3.) Completion of actions from HSIB reports. 
4.) Progress against actions outlined in the Maternity Safety Support Program. 
5.) Monitor progress against Trust’s action plans in response to CQC inspections. 
6.) Monitor Summary Hospital-level Mortality Indicators for the Trust. 

The time frame for completion is within the next three months to establish agreed 
frequency to meet with the Trust. 

Additional actions CQC propose to take (for completion within the same timescale) 
are: 

 
 
 
 
 
 
 
   
 
 
  
 
 
 
 
  
 
 
 
 
 
   
 
 
  
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
  
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1.) Monitor the Trust’s progress and compliance in implementing the national 

medical examiner system by April 2023. 

2.) Seek confirmation that the Trust have an established process for the isolation 
of any medical equipment involved when an event happens when equipment 
may be involved. 

3.) Information sharing and collaborative working with HSIB. 
4.) CQC will request information from the Trust which demonstrates compliance 

with Regulation 20: Duty of Candour. 

If CQC deems insufficient progress has been made by the Trust or if there is risk to 
service users, CQC will consider discharging its regulatory functions. 

Should you require further information from CQC, please contact us. 

Thank you in advance for your assistance. 

Yours sincerely 

Deputy Director (Interim) 
Acute Hospitals South East

Sent via email;  
Dr Karen Henderson,  
HM Assistant 
Coroner for West Sussex 

Chair and Chief Executive’s Office 

2nd Floor, Stewart House 
32 Russell Square 
London 
WC1B 5DN 

15 March 2023 

Dear Dr Karen Henderson  

RE:  – Regulation 28 Report   - Teegan Marie Barnard  

I write in response to your report of 17 January 2023, made under paragraph 7, Schedule 
5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners 
(Investigations) Regulations 2013. I have been asked to respond on behalf of Health 
Education England. Please may I start by offering my sincere condolences to the family of 
Teegan Marie Bernard, following her tragic death. However, having carefully considered 
the report, together with the facts of the case, we believe that whilst there are valuable 
lessons to be learned; Unfortunately, these do not come within the scope of HEE’s 
current role and statutory responsibilities. 

Your report raises concerns regarding both the care Teegan Marie Bernard received, 
together with the handling of evidence shortly after her death and the Trust’s obligations 
in relation to its statutory Duty of Candour. Your report also highlighted concerns around 
the Trust’s procedures and process for investigating an unexpected death. We 
acknowledge that the Chief Executive of Health Education England (HEE) has been 
identified as having a duty to respond and the report has also been sent by the coroner to 
other national bodies including:  

, Chief Executive U. Hospitals Sussex NHS Foundation Trust 

, Medical Director, St Richards Hospital, Chichester 

• 
• 
•  The Chief Executive NHS England 
•  The Chief Executive of the Care Quality Commission.  
•  President, Royal College of Anaesthetists 
•  President, Association of Anaesthetists Great Britain, and Ireland 

To respond to your concerns, I will first clarify HEE’s current role in relation to the 
education and training of the medical, nursing and health workforce. HEE is currently a 
non-departmental public body accountable to the Secretary of State and Parliament.  On 
the 1 April 2023, Health Education England will become part of a new organisation within 
NHS England. As part of the NHS, we work with partners to plan, recruit, educate and 
train the health workforce. HEE’s primary functions will continue; this being to serve the 
people of England by educating, training, and developing healthcare professionals. 
However, HEE does not have responsibility for decisions on the local NHS workforce or 
resources and nor do we mandate training or clinical procedure for consultant medical 
staff, this is the responsibility of local NHS Trusts.  

 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 We recognise that both the Ockenden Report and the review and report into maternity 
and neonatal services in East Kent: 'Reading the signals,’ have placed a much-needed 
focus on what now must be done to raise standards of care in maternity services. We are 
working to implement the Immediate Action Areas in the Ockenden Report.  This includes 
the recommendation that the Department of Health & Social Care (DHSC) must work with 
the Royal College of Obstetricians and Gynaecologists (RCOG) and HEE to consider how 
to deliver an adequate and sustainable level of obstetric training posts to enable trusts to 
deliver safe obstetric staffing over the years to come.  

Regarding the independent investigation led by 
 into failures in East Kent; 
like our system partners we are working at pace to ensure the four areas for action are 
considered and implemented: 

identifying poorly performing units 

• 
•  giving care with compassion and kindness 
• 
teamworking with a common purpose 
• 
responding to challenge with honesty 

HEE, together with our system partners acknowledge there are areas where the NHS 
must do much better and this is now informing our approach, in delivery of the workforce 
of the next 15 years. 

I would like to draw your attention to the work, which HEE has led on, around training in 
patient safety. This carefully designed training series is designed to be used by staff and 
clinical practitioners at all stages of their career and regardless of whether their roles are 
patient facing or not. This is because we believe that patient safety is everyone’s 
business. Patient safety training materials have been developed by Health Education 
England, with NHS England and NHS Improvement, The Academy of Medical Royal 
Colleges and e-learning for healthcare. Completion of this training is helping to ensure 
health and care services will be made as safe as possible for patients and service users. 

I hope this response provides assurance that steps are being taken to improve patient 
safety, together with ensuring the workforce has the appropriate knowledge and skills to 
deliver the very best patient outcomes. This is in line with the NHS Long Term Plan 
priority areas. 

Finally, on behalf of HEE, I thank you for bringing these matters to our attention and the 
awareness of others. 

Yours sincerely, 

Chief Executive

Dr Karen Henderson 
HM Coroner 
Record Office 
Orchard Street 
Chichester  
PO19 1DD  

Dear Coroner, 

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

11 April 2023 

Re: Regulation 28 Report to Prevent Future Deaths – Teegan Marie Barnard who 
died on 7th October 2019.  

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 17th 
January 2023 concerning the death of Teegan Marie Barnard on 7 October 2019. In 
advance of responding to the specific concerns raised in your Report, I would like to 
express my deep condolences to Teegan’s family and loved ones. NHS England are 
keen to assure the family and the coroner that the concerns raised about Teegan’s 
care have been listened to and reflected upon. 

I  am  also  grateful  for  the  further  time  granted  to  respond  to  your  Report,  and  I 
apologise for any anguish this delay may have caused Teegan’s family or friends.  I 
realise that responses to Coroner Reports can form part of the important process of 
family and friends coming to terms with what has happened to their loved ones and 
appreciate this will have been an incredibly difficult time for them.   

NHS England have reviewed the response to your Report from University Hospitals 
Sussex NHS Foundation Trust (hereafter "the Trust") whom we consider are the most 
appropriate  body  to  respond  to  the  concerns  raised.  We  note  that  the  Trust  has 
identified  learning  points  and  strengthened  its  training  for  relevant  staff  members 
following Teegan’s death as well as the ongoing improvement work to their maternity 
services, implemented through the Maternity Improvement Programme.  

Resuscitation  algorithm  (4  H’s  &  4  T’s)*  for  PEA  cardiac  arrest    and  surgical 
emphysema  

You  raised  the  concern  that  the  resuscitation  algorithm  of  4  H’s  (Hypothermia, 
Hypoxia,  Hypovolaemia,  Hypo/Hyperkalaemia)  and  4  T’s  (Tension  pneumothorax, 
Toxins,  Thrombosis,  Tamponade)  was  not  applied  adequately  following  Teegan’s 
cardiac arrest and that there was delay in recognition of surgical emphysema.  

The 4 H’s & 4 T’s algorithm is taught as part of the Advance Life Support (ALS) course, 
a  course  run  by  the  Resuscitation  Council  UK  and  aimed  at  those  healthcare 
professionals who need skills in ALS as part of their clinical duties, to include doctors, 
paramedics and nurses working in acute care areas. All anaesthetists, and all doctors 

                                                                                                                       
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 working in any environment where ALS would be required, to include obstetricians and 
senior members of the cardiac arrest team in this case, are expected to hold an up-to-
date  ALS  certificate  (or  equivalent)  and  be  across  the  latest  guidance  regarding 
resuscitation  and  cardiac  arrest.  Surgical  emphysema  is  covered  as  part  of  this 
course.  

Bilateral pneumothoraces occurring as it did in this case is rare and we note that both 
the  Royal  College  of  Anaesthetists  (RCoA)  and  Association  of  Anaesthetists  has 
stated that most anaesthetists will never encounter such a situation. NHS England’s 
National  Patient  Safety  Team  forms  part  of  the  Safe  Anaesthesia  Liasion  Group 
(SALG),  together  with  the  RCoA  and  the  Association  of  Anaesthetists,  who  will 
therefore be sharing the learnings from Teegan’s death across its network of relevant 
organisations.  The  national  Regulation  28  Working  Group  will  also  be  asking  its 
regional members to share the learnings with their Integrated Care Boards (ICBs) for 
onward sharing to Trusts across England.  

NHS England also consulted with the Resuscitation Council UK as part of its review 
of your Report. It should be noted that as a result of Teegan’s death, the Resuscitation 
Council reviewed the existing ALS guidance and materials, to include consultation of 
relevant  experts.  It  was  concluded  that  the  ALS  course  did  adequately  cover  the 
algorithm as well as cardiac arrest in pregnancy.  

Trust investigation and Clinical Governance procedures 

With regard to the concerns around the subsequent investigation into Teegan’s death, 
and the fact that there was no local investigation run in parallel to the Healthcare Safety 
Investigation  Branch’s  (HSIB’s)  investigation,  the  NHS  England  National  Patient 
Safety  Team  has  recently  launched  a  new  Patient  Safety  Incident  Response 
Framework  (PSIRF),  which  ‘sets  out  the  NHS’s  approach  to  developing  and 
maintaining effective systems and processes for responding to patient safety incidents 
for the purpose of learning and improving patient safety’.  

PSIRF states that “Where [an HSIB maternity] investigation is undertaken, a separate 
local patient safety learning response is not required. However, organisations should 
complete  Duty  of  Candour  requirements  (ahead  of  handover  to  HSIB  for  further 
involvement  of  patients/families  in  the  investigation).”  We  note  from  the  Trust’s 
response that they have reviewed and strengthened the process for decision-making 
around the local investigation of incidents when incidents are referred to HSIB.  

Regarding your concerns around there being no temporary removal of the anaesthetic 
machine used in this case, or the downloading of information from the machine, we 
welcome  RCoA’s  commitment  to  update  its  guidance  accordingly,  to  ensure 
responsibilities around this are made more explicit. We are also aware that the Care 
Quality Commission (CQC) will be issuing a response to your Report and will review 
their response and any recommendations made in due course.   

 
 
 
 
 
 
 I would also like to provide further assurances on national NHSE work taking place 
around the Reports to Prevent Future Deaths. All reports received are discussed by 
the Regulation 28 Working Group, comprising Regional Medical Directors, and other 
clinical and quality colleagues from across the regions. This ensures that key learnings 
and insights around preventable deaths are shared across the NHS at both a national 
and regional level and helps us pay close attention to any emerging trends that may 
require further review and action. 

Thank you for bringing these important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information. 

Yours sincerely, 

National Medical Director

8 March 2023 

Dear Dr Henderson, 

Re: Regulation 28: Report to Prevent Future Deaths in the matter of Teegan Marie Barnard 

Thank you for sending us a copy of your Regulation 28 Report regarding the sad death of Teegan 
Marie Barnard. We have jointly reviewed the information available to us in the report via our Safe 
Anaesthesia Liaison Group (SALG). SALG is a collaborative project between the Association of 
Anaesthetists, NHS England’s Patient Safety team and the Royal College of Anaesthetists. One of 
its core objectives is to analyse anaesthesia-related serious incidents and to share the learning 
with the specialty across the UK. 

Bilateral pneumothoraces occurring on emergence from a general anaesthetic, especially one 
for surgery that did not include thoracotomy or thorascopy, is so rare that most anaesthetists will 
never encounter such a situation. All anaesthetists are taught the 8 reversible causes of cardiac 
arrest through the Resuscitation Council’s Advanced Life Support course, or an equivalent, that 
they must complete as part of their training and maintain their competencies throughout their 
career. Bilateral pneumothoraces are mentioned only in the setting of trauma in the Resuscitation 
Council’s guidelines. For this reason, we will share the learning from Teegan’s death that bilateral 
pneumothoraces can be cause of failure to ventilate leading to cardiac arrest in the absence of 
trauma or thoracic surgery. We will do so via SALG’s Patient Safety Update, which is shared with all 
members of our respective organisations, and via our education and events. 

There are mechanisms to support staff to respond to challenging clinical emergencies, such as 
that described in your report. All organisations should have a clear system for calling for additional 
clinical support in emergency situations and it is clear from your report that this was in place at St 
Richards Hospital, Chichester. Cognitive aids, such as that produced by the Association of 
Anaesthetists1 can be helpful during a crisis when the cognitive load can impair performance. 
They are only effective, however, if the organisation has ensured that all staff are given the time 
to become practised in their use. In the recent Association of Anaesthetists and Difficult Airway 
Society publication on human factors in anaesthetic practice2 and in Royal College guidelines3, 
we recommend that this is done through multidisciplinary team training, so that the team that 
works together can learn together how to respond to unexpected or uncommon emergencies. 

Your report highlights the importance of reporting, investigating and sharing learning from critical 
incidents. The Royal College guidelines3 outline in detail the systems that departments should 
have in place to respond to critical incidents, emphasising both the need to investigate and 
embed the learning from such incidents and the importance of supporting patients, patients’ 
family and the staff involved.  

A systems-based approach to learning from patient safety incidents is acknowledged as the most 
effective way to understand how incidents happen and the factors that contribute to them, as 
included in both our guidance and the recently published NHS England Patient Safety Incident 
Response Framework. Both our guidance and the new framework also focus on the 
compassionate engagement of those affected by the incident, including staff members who 

  
 
 
 
 
 
 
 
 
 
 may be affected by the “second victim” phenomenon and be severely emotionally affected by 
this. Organisations should have formal, sympathetic and structured support available for all those 
affected by patient safety incidents. Patient safety incidents can be subject to multiple 
investigations from both within the organisation and by external bodies. Consideration should be 
given to how these are coordinated in order to reduce the duplication of effort, to ensure that 
the learning for the system as a whole can be embedded into practice as soon as feasible and to 
prevent compounded harm to those involved during the investigations.4 

We have reviewed our guidance in light of your report and we have recognised that we should 
be more explicit about the need for a standardised process of investigation which is 
automatically triggered immediately after a catastrophic event. This should ensure that 
responsibility for steps such as downloading information from the anaesthetic machine or the 
temporary removal of equipment from service for checking, is removed from those directly 
involved. We will amend our guidance accordingly, promote these changes to the specialty and 
embed this change into practice through the RCoA’s Anaesthesia Clinical Services Accreditation 
scheme. We also note that the implementation of our recommendation that all departments 
should have an appropriate electronic anaesthetic record system, linked to the wider electronic 
patient record, would aid the investigation of incidents. 

We would be happy to respond to any questions that you might have. 

Yours Sincerely 

President 
Royal College of Anaesthetists 

President 
Association of Anaesthetists 

References 
1.  The Association of Anaesthetists, Quick Reference Handbook, 2018 (updated 2019, 2021, 
2022) (https://anaesthetists.org/Home/Resources-publications/Safety-alerts/Anaesthesia-
emergencies/Quick-Reference-Handbook) 

2.  The Association of Anaesthetists and the Difficult Airway Society, Implementing human factors 

in anaesthesia: guidance for clinicians, departments and hospitals, 2023 
(https://anaesthetists.org/Home/Resources-publications/Guidelines/Implementing-human-
factors-in-anaesthesia-guidance-for-clinicians-departments-and-hospitals)  

3.  The Royal College of Anaesthetists, Guidelines for the Provision of Anaesthesia Services: The 

Good Department, 2021 (updated 2023) (https://www.rcoa.ac.uk/gpas/chapter-1)  

4.  NHS England, Patient Safety Incident Response Framework: Engaging and involving patients, 

families and staff following a patient safety incident, 2022 
(https://www.england.nhs.uk/publication/patient-safety-incident-response-framework-and-
supporting-guidance)

8 March 2023 

Dear Dr Henderson, 

Re: Regulation 28: Report to Prevent Future Deaths in the matter of Teegan Marie Barnard 

Thank you for sending us a copy of your Regulation 28 Report regarding the sad death of Teegan 
Marie Barnard. We have jointly reviewed the information available to us in the report via our Safe 
Anaesthesia Liaison Group (SALG). SALG is a collaborative project between the Association of 
Anaesthetists, NHS England’s Patient Safety team and the Royal College of Anaesthetists. One of 
its core objectives is to analyse anaesthesia-related serious incidents and to share the learning 
with the specialty across the UK. 

Bilateral pneumothoraces occurring on emergence from a general anaesthetic, especially one 
for surgery that did not include thoracotomy or thorascopy, is so rare that most anaesthetists will 
never encounter such a situation. All anaesthetists are taught the 8 reversible causes of cardiac 
arrest through the Resuscitation Council’s Advanced Life Support course, or an equivalent, that 
they must complete as part of their training and maintain their competencies throughout their 
career. Bilateral pneumothoraces are mentioned only in the setting of trauma in the Resuscitation 
Council’s guidelines. For this reason, we will share the learning from Teegan’s death that bilateral 
pneumothoraces can be cause of failure to ventilate leading to cardiac arrest in the absence of 
trauma or thoracic surgery. We will do so via SALG’s Patient Safety Update, which is shared with all 
members of our respective organisations, and via our education and events. 

There are mechanisms to support staff to respond to challenging clinical emergencies, such as 
that described in your report. All organisations should have a clear system for calling for additional 
clinical support in emergency situations and it is clear from your report that this was in place at St 
Richards Hospital, Chichester. Cognitive aids, such as that produced by the Association of 
Anaesthetists1 can be helpful during a crisis when the cognitive load can impair performance. 
They are only effective, however, if the organisation has ensured that all staff are given the time 
to become practised in their use. In the recent Association of Anaesthetists and Difficult Airway 
Society publication on human factors in anaesthetic practice2 and in Royal College guidelines3, 
we recommend that this is done through multidisciplinary team training, so that the team that 
works together can learn together how to respond to unexpected or uncommon emergencies. 

Your report highlights the importance of reporting, investigating and sharing learning from critical 
incidents. The Royal College guidelines3 outline in detail the systems that departments should 
have in place to respond to critical incidents, emphasising both the need to investigate and 
embed the learning from such incidents and the importance of supporting patients, patients’ 
family and the staff involved.  

A systems-based approach to learning from patient safety incidents is acknowledged as the most 
effective way to understand how incidents happen and the factors that contribute to them, as 
included in both our guidance and the recently published NHS England Patient Safety Incident 
Response Framework. Both our guidance and the new framework also focus on the 
compassionate engagement of those affected by the incident, including staff members who 

  
 
 
 
 
 
 
 
 
 
 may be affected by the “second victim” phenomenon and be severely emotionally affected by 
this. Organisations should have formal, sympathetic and structured support available for all those 
affected by patient safety incidents. Patient safety incidents can be subject to multiple 
investigations from both within the organisation and by external bodies. Consideration should be 
given to how these are coordinated in order to reduce the duplication of effort, to ensure that 
the learning for the system as a whole can be embedded into practice as soon as feasible and to 
prevent compounded harm to those involved during the investigations.4 

We have reviewed our guidance in light of your report and we have recognised that we should 
be more explicit about the need for a standardised process of investigation which is 
automatically triggered immediately after a catastrophic event. This should ensure that 
responsibility for steps such as downloading information from the anaesthetic machine or the 
temporary removal of equipment from service for checking, is removed from those directly 
involved. We will amend our guidance accordingly, promote these changes to the specialty and 
embed this change into practice through the RCoA’s Anaesthesia Clinical Services Accreditation 
scheme. We also note that the implementation of our recommendation that all departments 
should have an appropriate electronic anaesthetic record system, linked to the wider electronic 
patient record, would aid the investigation of incidents. 

We would be happy to respond to any questions that you might have. 

Yours Sincerely 

President 
Royal College of Anaesthetists 

President 
Association of Anaesthetists 

References 
1.  The Association of Anaesthetists, Quick Reference Handbook, 2018 (updated 2019, 2021, 
2022) (https://anaesthetists.org/Home/Resources-publications/Safety-alerts/Anaesthesia-
emergencies/Quick-Reference-Handbook) 

2.  The Association of Anaesthetists and the Difficult Airway Society, Implementing human factors 

in anaesthesia: guidance for clinicians, departments and hospitals, 2023 
(https://anaesthetists.org/Home/Resources-publications/Guidelines/Implementing-human-
factors-in-anaesthesia-guidance-for-clinicians-departments-and-hospitals)  

3.  The Royal College of Anaesthetists, Guidelines for the Provision of Anaesthesia Services: The 

Good Department, 2021 (updated 2023) (https://www.rcoa.ac.uk/gpas/chapter-1)  

4.  NHS England, Patient Safety Incident Response Framework: Engaging and involving patients, 

families and staff following a patient safety incident, 2022 
(https://www.england.nhs.uk/publication/patient-safety-incident-response-framework-and-
supporting-guidance)

St Richard’s Hospital 
Spitalfield Lane 
Chichester 
West Sussex 
PO19 6SE 

14th March 2023 

Dr K Henderson 

Assistant Coroner for the County of West Sussex 

Coroner’s Office 

West Sussex Record Office 

Orchard Street 

Chichester 

West Sussex 

PO19 1DD 

Dear Dr Henderson,  

RE: Regulation 28 Report to Prevent Future Deaths – Teegan BARNARD 

I am writing in response to the Regulation 28 Report issued following the Inquest into the death of Teegan 
Marie Barnard.  

Following Teegan’s death there has been intense focus to ensure that our maternity services are of the highest 
quality and are safe, and this is ongoing.  

Following the CQC visit to our maternity services in 2021 we have worked with the Maternity Safety Support 
Program (MSSP) and developed our Maternity Improvement Program (MIP) with their support. 

We have also worked hard to achieve the requirements of year 4 of the Clinical Negligence Scheme for Trusts 
(CNST). The Trust achieved 154 of the 155 requirements for our submission which is a huge achievement and is 
indicative of our focus on the safety of our maternity services.  Our evidence was rigorously assessed by the 
internal auditors (BDO) and reviewed by the Local Maternity and Neonatal system governance lead and ICB 
panel.   

The Trust is also confident that the staff involved worked to the best of their abilities during this tragic event. 

In the Regulation 28 Report concerns are raised about the following issues. 

1. The resuscitation algorithm (4H’s and 4T’s) for PEA arrest
2. Surgical emphysema
3. The Investigation following Teegan’s death.

 
 
 
 4.  Trust Clinical Governance procedures. 

Our responses are outlined below but also address matters of factual accuracy. 

(1) The resuscitation algorithm and (2) surgical emphysema 

You have raised concerns that although there are 8 contributory causes of Pulseless Electrical Activity (PEA) 
cardiac arrest (the 4H’s and 4 T’s), only one of these, tension pneumothorax, also causes a sudden inability to 
ventilate a patient; it was therefore determined that there was a delay in the team identifying this as the cause 
of the PEA arrest. Concern has also been raised that there was a delay in the team identifying surgical 
emphysema despite the presence of indicative signs.  

The Trust has been copied into the PFD response from the Royal College of Anaesthetists and UK Anaesthetic 
Association and note their comment that Bilateral pneumothoraces occurring on emergence from a general 
anaesthetic, especially one for surgery that did not include thoracotomy or thoracoscopy, is so rare that most 
anaesthetists will never encounter such a situation.   

However, the Trust recognises that for staff to perform optimally in extremely challenging situations such as 
maternal cardiac arrest appropriate training is essential. The Trust has therefore taken action to ensure all the 
appropriate members of the Multi-Disciplinary Team (MDT) have received the necessary training to be able to 
manage obstetric emergencies. An audit conducted in January 2023 demonstrates that over 90% of the 
obstetric, anaesthetic and midwifery staff that work within the labour ward environment across the entire 
organisation had received this MDT training. This reaches the stringent standards set for training by the Clinical 
Negligence Scheme for Trusts year 4 requirements. Of note maternal collapse has been a scenario within the 
training program since the beginning of the year and includes reference to the 4H’s and 4T’s. 

There has been a strong commitment to learning from these events from the anaesthetic team as well as the 
wider MDT.  The following points demonstrate that commitment: 

a.  Team learning at structured clinical governance events.  
b. 

Inclusion of the management of tension pneumothorax in the regular SIM sessions for the anaesthetic 
trainees at St. Richard’s Hospital. This includes the significance of facial swelling and surgical 
emphysema. The trainers are planning SIM demonstrations of all the national anaesthetic regulation 28 
notices and will play the recordings at teaching and clinical governance meetings. 

c.  The Trust’s anaesthetists have carefully reviewed The Royal College of Anaesthetists (RCA) guidance on 
the management of increased airway pressure for the ventilated patient which forms part of their 
Quick Reference Guide to Anaesthetic Emergencies Quick Reference Handbook (QRH) | The 
Association of Anaesthetists. Although the current handbook does not refer to surgical emphysema or 
tension pneumothorax in the management of increased airway pressures, we also note that, in their 
response to the PFD, the RCA and AA will share the learning that bilateral pneumothoraces can be a 
cause of failure to ventilate leading to cardiac arrest in the absence of trauma or thoracic surgery- 
through the SALG’s Patient Safety Update.  

We believe that it is important that the evidence of 
inquest is considered as context to the findings of the Regulation 28 Report. 
reflect on the actions of the team and are shown below. 

, the obstetric anaesthetic expert witness at the 
 verbatim comments 

 
 
 
 
 “I am satisfied that the medical team that responded and were working in the early hours of 10th September, 
their actions were reasonable and what was done, was done in a timely manner”. 

“I am satisfied that the team were thinking what on earth could have caused this. There was anaphylaxis and or 
angioedema, as a combined diagnosis and they were thinking what has this patient had - a Caesarean section, 
Post-Partum Haemorrhage, therefore the H (Hypovolemia) due to massive blood loss was such they pre-
emptively without any evidence of blood loss activated the major obstetrics haemorrhage plan, I think the 4 H’s 
and 4 T’s were being thought of.” 

“Having read the statements and putting myself in the position of this team, although they were treating, it was 
not blind or obvious. I don’t think I would have stuck needles in the chest earlier. The opening of the abdomen 
was 2- fold; to release the gas but also to stop any bleeding. The most likely (cause of) deterioration of a woman 
who collapsed (on labour ward), looking as an obstetric anaesthetist, is that there has been some sort of 
catastrophic haemorrhage, because that is where the surgical activity has been, they opened the abdomen, 
released the gas and ROSC and there was no bleeding.” 

(3) Investigation after Teegan’s Death 

The coroner raises the concern that there was no local investigation by the anaesthetic team before or after 
the HSIB report. However, initiating a local investigation in parallel to the HSIB investigation would have been 
contrary to national guidance. 

The Trust followed the recognised process for a maternal death and the incident was notified as a Serious 
Incident with a 72-hour report submitted at the appropriate time. This was followed by notification to HSIB. 
The incident fits the HSIB criteria, and the appropriate guidance was followed in response to the event. Of 
note, the guidance to Trusts from HSIB states: -  

Our maternity investigations have replaced a trusts' internal maternity serious incident investigations. We 
involve the trust and share the investigation reports as they are completed. Trusts continue to investigate 
maternity events that fall outside the specified criteria. (Information for trusts and staff — HSIB) 

The anaesthetic team cooperated fully with the HSIB investigation and responded comprehensively to the draft 
report. The outputs were discussed at length within the Trust in a number of forums and continues to be, 
including at the Intensive Care and Maternity Mortality and Morbidity meetings. This feedback was not fully 
reflected in the final report. 

Trust Clinical Governance Procedures 

Although the Trust followed existing national guidance, additional safeguards have been put in place to ensure 
our processes for investigating maternal deaths are robust. In the Regulation 28 notice, the Trust’s decision not 
to undertake a local investigation alongside the one initiated by HSIB is highlighted. At the inquest the Trust 
presented evidence demonstrating the very clear national guidance indicating that the HSIB investigation 
should replace the need for local scrutiny as described above. However, in response to the coroner’s concerns, 
the Trust has developed a draft SOP that defines the actions required when an HSIB investigation takes place 

 
 
 
 
 
 and includes consideration of the need or otherwise for a parallel local investigation. This will be ratified by the 
end of March 2023. 

As an organisation we are proud of our record of learning from deaths and working to improve preventable 
mortality. Improvements in mortality are both True North and Breakthrough Strategic Objectives at the trust – 
the latter with a specific focus on improving the recognition and management of the deteriorating patient. As 
an organisation, Learning from Deaths processes are well developed and scrutinised closely by our Quality 
Committee and Trust Board on a quarterly basis. 

In terms of wider learning in this specific case, senior representatives from the safety and clinical leadership 
teams, as well as the whole team of senior clinicians involved, attended the inquest and listened carefully 
throughout in this complex case.  

Factual accuracy 

We raise two matters in respect of the factual accuracy of the Regulation 28 Notice in respect of the following 
passage of text.  

‘At  or  around  0545  with  the  enduring  PEA  cardiac  arrest,  an  ongoing  inability  to  ventilate  by  any  means 

possible,  and  the  continuing  absence  of  chest  movement  and  breath  sounds  on  auscultation,  the  whole-body 

swelling  was  recognised  to  be  due  to  surgical  emphysema  from  a  presumptive  diagnosis  of  bilateral  tension 

pneumothoraces. At or around 0548 hours bilateral thoracostomies were undertaken with return of spontaneous 

circulation.’ 

The Regulation 28 Report indicates that the PEA cardiac arrest began at 0510-0515 with a return of 
spontaneous circulation (ROSC) at 0548 which occurred with the treatment of the tension pneumothoraces. 
We believe the duration of the cardiac arrest and timing of the return of spontaneous circulation stated in the 
Regulation 28 report are inaccurate. Evidence provided by HSIB in their investigation report (p 27-28) indicates 
that ROSC occurred 13 minutes earlier at 0535. This is corroborated by the Defibrillator records that indicated 
that the cardiac arrest lasted 17 minutes.  

The evidence provided by the Trust based on the clinical record also indicated that ROSC occurred earlier than 
the coroner records, and when the abdomen was opened alleviating the intrabdominal pressure, prior the 
drainage of the tension pneumothoraces. 

Modern defibrillators provide real-time feedback on the quality of resuscitation, and it is of note that the 
analysis of the quality of CPR provided throughout the event was excellent with minimal interruptions. 

Summary 

In summary the Trust: 

•  Has developed and implemented a Maternity Improvement Program,  
•  Has achieved a very strong year 4 CNST submission.  
•  Has provided a robust program of training for the multidisciplinary group of staff working on our labour 

wards that prepares them for situations such as this.  

 •  Has reviewed and strengthened processes for decision making about the local investigation of incidents 

referred to HSIB. 

As an organisation we are committed to providing the highest quality maternity services and believe our 
commitment to the Maternity Improvement Program and achievements in governance, the Clinical Negligence 
Scheme for Trusts Year 4 submission and training for the multidisciplinary team demonstrate this.  

Finally, our thoughts and sympathy are with Teegan’s family; we recognise just how this has been the most 
traumatic event for them and on behalf of University Hospitals Sussex NHS FT, I want to extend my sincere 
condolences.  

Yours sincerely 

Chief Executive