Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0059, written 15 Feb 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 15 Feb 2023 |
|---|---|
| Reference | 2023-0059 |
| Deceased | Raniya Khan |
| Coroner | Heidi Connor |
| Coroner area | Berkshire |
| Category | Child Death (from 2015) · Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Royal Berkshire NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Acting Chief Executive, Royal Berkshire NHS Foundation Trust 1 CORONER I am Mrs Heidi J. Connor, senior coroner 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 death of Raniya Rizwan Khan at Reading Town Hall, which concluded on 9th February 2023. I recorded a conclusion of natural causes. Her cause of death was : 1a Multi-organ failure 1b Severe arterial pulmonary hypertension of unknown cause 4 CIRCUMSTANCES OF THE DEATH Raniya was born at 07:52 hours on 9th May 2020. Although I heard evidence about her attendance at the day assessment unit (‘DAU’) the day before the birth, and about her neonatal management, the focus of the inquest was on her labour management from the time of her admission to the labour ward at 03:45 on 9th May. Her care by a band 6 agency midwife from that time until shift change at around 7am was the focus of the investigation. I found in evidence that this midwife: 1. Failed to recognise a pathological trace. Both the trust’s internal investigation and the report of an independent expert concluded that it should have been classified as pathological from 06:40 hours. This was largely because of reduced variability. 2. Conducted so called ‘fresh eyes’ reviews herself for this patient, rather than asking a colleague to do so. The reasons she gave for this significant, repeated and undocumented deviation from policy were inconsistent with the rest of the evidence, and I found them unlikely to be true. 3. Recorded the maternal rather than fetal heart rate for part of the trace. My understanding is that this can happen (briefly) even in experienced hands, but this was not recognised at the time by the midwife. 4. Did nothing to escalate or investigate the mother’s high pulse rate. 5. Did not take regular temperature readings, despite spontaneous rupture of membranes happening some hours before, when Mrs Rizwan was admitted to the DAU and was given paracetamol for a raised temperature. Raniya was transferred to Great Ormond Street Hospital on 15th May 2020, when her condition deteriorated. Despite extensive consideration and re-consideration of all relevant treatment options, Raniya died at Great Ormond Street Hospital on 28th May 2020. I concluded that earlier delivery was unlikely to have changed the outcome. Despite extensive investigation (including genetic investigations) at a very senior level, it has not been possible to identify the cause of Raniya’s pulmonary hypertension. 5 CORONER’S CONCERNS I sent a regulation 28 report to this trust on 20th June 2022, in relation to the death of a 6-day old baby born at Royal Berkshire Hospital on 26th June 2020. The circumstances of that case are different from these, but midwifery training and placenta retention are issues common to both cases. Placenta retention In their response to my previous Regulation 28 report, the trust said : 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 monitors are operating in the fridges, which provide connected automated 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 10th October 2022; it provides guidance on which placentas need to be sent to histology for pathological 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 coordinators will be trained on the new SOP to ensure compliance throughout maternity, and in particular the midwives and community support workers. We are also working with waste management to ensure that their team are fully aware of the new processes, as they now need to request that a member of the midwifery team attends with them to ensure the correct procedures are followed. As an additional assurance, the safety huddle templates on our electronic patient system will be updated to prompt the team to ask whether any babies have deteriorated or been admitted from other areas in the last 24 hours to the pediatric wards, 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 lack of communication between the maternity unit and pediatric ward. It was surprising in the extreme to be made aware in open court on the final day of this inquest that these undertakings have not in fact been completed – the system referred to above is not in place, there is no SOP, nor has there been any staff training. It was particularly disappointing to hear this in front of a family who had themselves lost a baby and who were being reassured of how committed the trust is to improvement. Midwifery training and management I was also advised that there has been no approach made to NHS Professionals about concerns with the midwife in question. Similarly, no approach to the NMC has been made. It is fair to recognise that this trust is focused on improving obstetric and midwifery care, and they have increased their training and staffing – to include appointing a director of midwifery. Changes have been made regarding induction of agency staff. It seems likely that individual people in these new posts have a clear desire to improve the service and are themselves somewhat frustrated that these changes have not yet been made. I would ask therefore that the trust respond within the requisite 56 days (at the latest) in relation to the following issues: 1. The current position with regard to : a. Storage of all placentas for 48 hours, and SoP around this b. Review of policies and staff awareness regarding mandatory sending of placentas for pathological examination. 2. Training and awareness regarding these new policies – to include practical arrangements around ensuring a placenta is retrieved and sent to histology subsequently if needed. 3. The trust should refer concerns about this individual agency midwife as a matter of urgency both NHS Professionals, and to the Nursing and Midwifery Council. This is in addition to raising of the possibility of an individual ‘passport’ to prevent a midwife moving between agencies to work elsewhere after significant concerns have been raised. 6 ACTION SHOULD BE TAKEN In my opinion, action should be taken to prevent future deaths and I believe you (and/or your organization) 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 14th April 2023. I, the coroner, may extend the period, however I have already indicated that an extension is unlikely to be granted in this case, given that these are not new issues. 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 Raniya’s family. I have also sent a copy of this to : , Chief Executive, NHS Professionals , Chief Executive, Nursing and Midwifery Council Although NHS P and NMC are not required to submit a formal response, I am mindful of their roles in training, assessment (for NHS P) and registration of midwives (for NMC) It is likely that, should a similar case arise, I will include them as Interested Persons. 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 15th February 2023 Mrs Heidi J. Connor Senior Coroner for Berkshire
2 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
t.!1:k1 Essex Partnership University NHS Foundation Trust Patient Safety Incident Management Team The Lodge Lodge Approach Wickford Essex SS11 ?XX 27 May 2022 Private and Confidential Mr Sean Horstead HM Area Coroner Coroner's Office Seax House Victoria Road South Chelmsford CM11QH Dear Mr Horstead, I am writing to set out the Trust's formal response to the report made under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, dated 25th February 2022, which was issued following the inquest into the death of Stephanie Moyce. I would like to begin by extending my deepest condolences to Stephanie's family and friends. This has been an extremely difficult time for them and I hope that my response provides her family, and you, with assurance that the Trust takes their loss seriously and has taken action to address the issue of concern raised in your report. You raised four matters of concern for EPUT, and I have provided a response for each of the points: 1. Evidence confirmed a conspicuous lack of clarity as to who, amongst EPUT clinicians/staff, is responsible for ensuring that a clear and comprehensive discharge plan is formulated for those coming to the end of a course of psychotherapy where a Care Coordinator is no longer in place/has not been replaced. for the need improvements related The Clinical Review under the Patient Safety Incident Response Framework (PSIRF) also to patients who are discharged from highlighted psychotherapy to ensure their care pathway is clear. The Clinical Review recommended for the psychotherapy discharge letter to be updated to include prompts for the psychotherapist to consider discharge planning. Following completion of the Clinical Review and of Stephanie's inquest, psychotherapy departments have updated their discharge letters. The letter now includes a free-text box for the psychotherapist to consider whether a patient is on the Section 117 register, and what the patient's discharge plan is after psychotherapy has concluded. This includes those who have an allocated care coordinator, and for those who do not. The discharge letter is sent to the patient's GP and there is a free-text box for the psychotherapist to include specific follow-up actions for the GP, where required. The discharge letter is to be used across the Trust. 2. Evidence confirmed a conspicuous lack of clarity as to who, amongst EPUT clinicians/staff including has responsibility for ensuring adequate and appropriate safety-netting is in place in the event of relapse, where a Care Coordinator is no longer in place/has not been replaced. for oversight of patient care following discharge, the responsibility Patients who are subject to Section 117 reviews or who have a care package, all require a review of their needs yearly. If such patients had a therapeutic intervention and a decision had been made that their risk is low and they do not require an allocated clinician, the patients will be 'banked' under the team's Service Manager. The details of the patient are presented in a spreadsheet and are monitored by the community team's administrators and the Section 117 review team. The teams receive notification of reviews on a three monthly basis indicating when their yearly review is due. In addition, two identified staff members make telephone contact with all of the patients on the 'banked' list. They update the patient's risk assessment and determine whether the patient may require increased intervention. This is across Colchester and Tendring, where Stephanie was in receipt of services. 3. Evidence confirmed that patients under psychotherapy are not presently routinely discussed in the locality multi-disciplinary team meetings prior to their discharge leading to a missed opportunity: (a) to share information about the specific progress, vulnerabilities and risks of relapse of the patient (and measures to mitigate or deal with the same); as well as (b) to organise and follow up the overall discharge planning. Where patients are on Section 117 aftercare plans and under psychotherapy, there will be written communication with the locality MDT team prior to their discharge to share their progress and highlight concerns around risk and further needs, including the need for follow-up and the arrangements of this. 4. The evidence in this case indicated that, contrary to EPUT's own established Protocol, a patient's carer (in this case her long-term partner where no confidentiality issues were identified) are not in practice always "seen as equal partners in the development and review of Section 117 after-care plans" and involved directly in such reviews. The Trust acknowledge and agree with the concern in which you raise. In order to enhance the system which is already in place, and ensure the policy is incorporated into daily practices the Care Programme Approach review (CPA) documentation across Mobius and Paris will be updated. The CPA review document will include a 'yes/no' answer to whether a patient's family/partner/carer have been involved in the review process and meetings. If the clinician selects 'no', this will generate a free-text box to provide reasons as to why they have not been involved. Prompts will be included within the template around the limitations to confidentiality discussed with the patient. I hope that I have provided you with robust assurance that the Trust has taken steps to address the issues of concern in your report, that we are continuing to take action to strengthen the care provided to our patients, and that patient safety is the Trust's top priority. Yours sincerely, Chief Executive 2
Private & Confidential Mrs Heidi Connor Senior Coroner for Berkshire Berkshire Coroners' Office Reading Town Hall Blagrave Street Reading, RG1 1 QH r.•1:bj Royal Berkshire NHS Foundation Trust Executive's Office Royal Berkshire Hospital Level 4, Main Entrance London Road Reading Berkshire RG1 SAN Tel: 0118 322 7230 www. royalberksh ire . nhs. uk 04 April 2023 Response to Regulation 28 Report to Prevent Future Deaths Dear Mrs Connor I am writing in response to the Regulation 28 Report issued following the Inquest into the death of Raniya Rizwan Khan . We hope that this response provides reassurance that the Trust has acknowledged the concerns raised and responded appropdately and timeously to them . 1. a. The current position with regard to : Storage of all placentas for 48 hours, and SoP around this Following the regulation 28 report sent to the tr.ust on 20th June 2022 actions were taken to enable a robust process for sending placentas for histological examination. This included a process to ensure the storage of all placentas for 48 hours from the time of birth. The Standard Operating Procedure (MATSOP064) detailing these changes was ratified at the maternity clinical governance meeting on 7th October 2022. · The placenta fridges were procured in August 2022 however they were both found to be faulty and replacements had to be requested. These arrived on 31 st October. These were placed in the Delivery Suite and Birth· Centre and fitted with appropriate alarms to allow automated monitoring and alerts to be received in the clinical areas should there be any concerns with the temperature of. the fridge. Unfortunately these alarms were subject to interference from another automated system used within the Trust. This was identified at the end of December 2022. We would like to apologise for not updating the Coroner of this unexpected issue which prevented the implementation of the new process. The issue was resolved by 1st February 2023 and the new process was fully implemented on Monday 13th February. In practical terms all placentas are now stored for 48 hours. The midwife coordinating the intrapartum areas is responsible for releasing these to the waste disposal team having identified all placentas that need to be sent for examination during this time. The Daily Safety Huddle is held in the middle of the ·day by the midwife coordinating the delivery suite .. The huddle identifies and discusses any babies that r~1:bj Royal Berkshire NHS Foundation Trust ' have died, or have been admitted to the neonatal unit requiring ventilation or cooling, and are under 48 hours of age. The placentas of these babies are then retrieved and sent for histology by a member of midwifery staff. All other placentas beyond 48 hours from the birth, are highlighted with a green sticker and moved to the bottom of the fridge. Only placentas stored on the bottom two shelves displaying the green stickers are released to the waste management team . b. Review of policies and staff awareness regarding mandatory sending of placentas for pathological exanJination. The Placenta Examination Guideline (GL886) has been amended to signpost to the new SOP and this was ratified on 7th October 2022. " 1st From February 2023 various communication strategies have been used to highlight the new processes with all midwifery and support staff. This focusses on highlighting the circumstances in which placentas must be sent for examination, the need ·for all placentas to be stored for 48 hours and processes for disposal. Posters are displayed on the comhluf"!ication boards and fridges and verbal communication has been undertaken at each handover. A series of training videos were made which show how to store the placentas following a home or hospital birth, how to send a placenta for histology and how to retrieve a placenta within 48 hours for sending for histology or safe disposal. The training videos also signpost the member of staff to the new SOP. Initially these videos were sent to staff via social media however from · 13th February 2023 they have been included on the Trust Learning Matters platform and all midwives have been made aware through multiple communication channels that they are required to undertake this training .. This will be evidenced through reports pulled from the platform by the practice development team each week and forwarded to the Director of Midwifery. To date 98% of midwives have received this training and individual reminders have been sent to those who still need to do so. 2. Training and awareness regarding these new policies - to include practical arrangements around ensuring a placenta is retrieved and sent to histology subsequently if needed. These points are addressed above in response to 1 (a) and 1 (b). 3. The Trust should refer concerns about this individual agency midwife as a matter of urgency both NHS Professionals, and to the Nursing and Midwifery Council. This is in addition to raising of the possibility of an individual 'passport' to prevent a midwife moving between agencies to work elsewhere after significant c~ncerns have been raised. The Trust raised the concerns about the individual agency midwife on Friday 10th February 2023 and have received confirmation that the agency are meeting with the .midwife to investigate these concerns. The Trust have taken advice from the NMC employer link service and a referral was submitted on 22nd February 2023. The Trust accepts that it should have made every effort to feedback the findings of the internal investigation to the agency irrespective of whether the midwife was continuing to work for the Trust. The Trust have processes in place for providing feedback to agencies and we are now doing this in all situations. We are also strengthening the _policy around reporting concerns in situations where staff no longer work at the Trust, and ensuring that the Policy is explicit in its requirement to do so. The Trust'.s learning .culture and transparency was recognised by an Ockenden Assurance and Insight visit led by r.•1:bj Royal Berkshire NHS Foundation Trust the Regional Chief Midwife in September 2022. This was fed back verbally to members of the maternity senior leadership team and Trust exec at the time of the visit. The issue of how, and where, to feedback on temporary staff when they have left a specific Trust after a period of employment was raised at a regional Buckinghamshire, Oxfordshire and Berkshire Local Maternity and Neonatal System (BOB LMNS) Serious Incident Review meeting soon after this investigation was concluded . It was deliberated if a joint set of standards and/or processes for Agency staff should be drafted on a .regional or national level in collaboration with the Nursing and Midwifery Council (NMC). This was an action that the regional LMNS team were cdnsidering . Upon further deliberation and reflection, the Trust considers that this is a matter for the regulator because a national solution is required and this is beyond the means of a single Trust. The Director of Midwifery , who has discussed this with the Chief has raised this with the Regional Chief Midwife, - Midwife for England and the NMC. As a result recomf"!lendations will be sent to organisations reminding them that serious concerns over practice of an agency member of staff should be referred to the agency and ·NMC. In addition there are plans in place to convene a group including providers, LMNS, region and Health Edu.cation England to ensure there is a standardised approach to the orientation and immediate support provided to agency staff. The Trust are committed to continually improving our midwifery and obstetric care, and believe the points outlined above demonstrate our dedication to doing so. In summary, the Trust have implemented ·a robust process for sending placentas for histological examination, including the Standard Operating Procedure (MATSOP064) ensuring storage of all placentas for 48 hours from the time of birth, ratified at the maternity clinical governance meeting on 7th October 2022. As of 13th February 2023, the new process is now fully operational. A variety of strategies have been used to communicate these processes to relevant staff. The Trust are also strengthening the Policy for feedback of concerns raised about temporary agency staff. The wider issue was raised with the BOB LMNS and Regional Chief Midwife to take forward. We hope this response allays the concerns you have raised, and provides you and the family of Raniya with assurances that the Trust have taken your concerns for future patients' safety seriously by implementing actions surrounding the storage of placentas, training and awareness of new policies and procedures, and the feedback of concerns raised about agency staff. We hope this demonstrates the Trust's commitment to the continuous improvement of our services. If you require any further information or evidence, plea.se do not hesitate to contact us. Yours Sincerely, Acting Chief Executive Officer
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