Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0095, written 16 Mar 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Mar 2023 |
|---|---|
| Reference | 2023-0095 |
| Deceased | Rachael Walker |
| Coroner | Peter Nieto |
| Coroner area | Derby and Derbyshire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS
NOTE: This form is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT DEATHS
THIS REPORT IS BEING SENT TO: -
The University Hospitals of Derby and Burton NHS FT
1 CORONER
I am Peter Nieto, Area Coroner for the coroner area of Derby and Derbyshire.
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 9 August 2022 I commenced an investigation into the death of Rachael Chloe WALKER aged
36. The investigation concluded at the end of the inquest on 3 March 2023. Article 2 of the
European Convention on Human Rights was engaged due to the relevance to Chloe’s death of
hospital Trust policies and systems. The conclusion of the inquest was: -
Chloe died of the effects of placental haemorrhage and amniotic fluid embolism at week thirty-
seven of her pregnancy due to diagnosed placenta praevia. It is probable that her death would
have been avoided if a delivery plan made for her had been recorded in her notes and acted
upon, and if the relevant Trust had incorporated national guidance issued in September 2018
which provided for consideration for earlier caesarean delivery.
4 CIRCUMSTANCES OF THE DEATH
Rachael Walker, known as Chloe, died in hospital on 19 June 2021 due to experiencing a
placental haemorrhage and amniotic fluid embolism at the thirty seventh week of her
pregnancy. Chloe had been diagnosed with placenta previa during her antenatal care.
Chloe had antepartum haemorrhage at home on the early morning of 19 June 2021 and had
to be taken to hospital by ambulance. At the maternity unit she experienced further
haemorrhage and was taken for emergency caesarean section. Her baby was delivered but
Chloe quickly went into the first of three cardiac arrests. On the evidence it is not apparent
that there was a postpartum haemorrhage, but she did develop blood clotting disorder and
disseminated bleeding, likely related to the placental haemorrhage and amniotic fluid
embolism. Chloe sadly died in the operating theatre despite prolonged resuscitation attempts.
Chloe had recognised risk factors in her pregnancy and the consultant obstetrician with lead
responsibility for her care decided at an appointment at week thirty-four of Chloe’s pregnancy
on a plan to review Chloe at an appointment at week thirty-seven, with a view to offering
hospital admission and planned caesarean section by week thirty-eight due to the placenta
previa. That plan was not recorded in Chloe’s notes with the result that the obstetric registrar
who saw Chloe at week thirty-seven was unaware of the plan. Furthermore, the relevant
hospital Trust had not adopted national guidance issued in September 2018 for consideration
of delivery by caesarean section between weeks thirty-six and thirty-seven in Chloe’s
circumstances. Consequently, Chloe was booked for planned caesarean section at week thirty-
eight as per Trust guidance. At inquest the Trust accepted these were missed opportunities to
Regulation 28 – After Inquest
Document Template Updated 30/07/2021
avoid Chloe’s death and had they not been missed it is likely that Chloe would not have died
because delivery would have occurred well before 19 June, or, if antepartum haemorrhage had
successfully managed.
occurred
it would
admission,
during
been
have
Although not clearly causal or contributory to Chloe’s death, I identified the following serious
issues from the evidence: -
• The maternity unit did not have a system or proforma to note down and pass on to
clinicians information provided by the ambulance service via the dedicated phone line
unit.
to
the
• Blood for urgent use in maternity unit surgery was not kept on or near to the maternity
unit.
• There was delay in calling for the on-call consultant anaesthetist to attend once the
emergency caesarean section had been called.
• There was no robust system in place for a major obstetric haemorrhage to be called
and acted upon with resulting delay in the provision and use of blood products.
• There was insufficient co-ordination and oversight of the emergency team and roles
and tasks in the surgical theatre, in particular in oversight of obtaining and use of blood
products.
• Certain key equipment was not available for the maternity unit theatre: -
- A blood storage fridge.
- Warming equipment for women during surgery.
Point of care testing anticoagulation equipment.
-
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: -
My principal concern is that having heard evidence from the Trust as to ‘lessons learnt’ and its
current processes for identifying when Trust clinical policies and guidance needs updating, and
where essential equipment needs to be obtained and located, I remain unclear that the Trust
now has sufficiently robust processes in place to prevent similarly avoidable deaths to that of
Chloe. Indeed, I am unclear that the processes are substantively different to those that existed
at the time of Chloe’s death.
It was of very particular concern to hear that clinicians at the time were aware of revised
national pregnancy guidance issued in September 2018 but this had not been incorporated into
Trust policy and guidance. I was told that introducing revised guidance was necessarily complex
and lengthy and yet the Trust did incorporate the revised guidance just several weeks following
Chloe’s death and it appears because of her death. It was also very concerning to hear that the
Trust had established a regional pregnancy service using out of date guidance. Certain changes
relating to the circumstances of Chloe’s death have only very recently been addressed or are
in process; for example, the procedure to call and respond to a major maternal haemorrhage
was to be tested a week or two after the inquest.
I therefore consider that the Trust should review its processes for identifying when Trust clinical
policies and guidance needs updating, and where essential equipment needs to be obtained
Regulation 28 – After Inquest
Document Template Updated 30/07/2021
and located, in the interests of preventing future deaths, and that those processes should
ensure timely revisions and associated actions.
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 May 11, 2023. 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:-
•
(partner of Rachael Chloe Walker)
• University Hospitals of Derby and Burton NHS FT
•
East Midlands Ambulance Service
I have also sent it to: -
•
•
Health Service Investigation Branch (maternal deaths)
Care Quality Commission
who may find it useful or of interest.
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: 16 March 2023
Peter Nieto
Regulation 28 – After Inquest
Document Template Updated 30/07/2021
Area Coroner
Derby and Derbyshire
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.
PRIVATE & CONFIDENTIAL Mr P Nieto HM Area Coroner for Derby and Derbyshire St Katherine's House St Mary's Warf Mansfield Road Derby, DE1 3TQ 11 May 2023 Dear Sir I am writing in response to the Regulation 28 Report dated 16 March 2023, following the Inquest into Mrs Walker's sad death. I firstly want to begin by offering my sincere condolences to Mrs Walker's family and give an assurance that the Trust has taken significant steps to address the concerns that you raised. I note that you have identified two broad areas of concerns relating to governance processes relating to clinical guidelines and equipment. Please find enclosed commentary that I have prepared to given assurance around the actions taken as a result of Mrs Walker's death and following the Prevention of Future Death Report. By way of further assurance, the Trust has retained 360 Assurance to audit the measures taken by the Trust, which will include an audit of the following: • • the structure, roles, responsibilities, attendance and reporting arrangements the quality of the minutes and actions including scrutiny and challenge regarding risks, issues and concerns including documentation of these, responsibilities and escalation • a review of the functioning and effectiveness of the Maternity Services Risk • and Governance Strategy the effectiveness of the governance across all sites with equal consideration being given to risks, issues and concerns across all sites. The Trust is committed to transforming our maternity services. The Trust's Improvement Action Plan covers the steps we need to take to improve our compliance against Saving Babies’ Lives, Ockenden recommendations, the maternity incentive scheme, locally agreed from actions and recent external reviews of our service. Having everything in one place means we can prioritise, track and measure progress, and clearly hold ourselves to account on when we are going to deliver each action within it. To support this, we will be implementing a project 1 management approach to make sure workstreams are coordinated, and that we use all opportunities to engage with staff and service users. Within the Local Maternity and Neonatal System (LMNS) the Trust reports to the Perinatal Quality and Safety Group (PQSF) each month to ensure accountability for the quality and sustainability of services alongside transformation and improvement activity. The PQSG escalate issues, concerns and risks to the ICS or regional governance structures. Furthermore, the Trust Board has approved and are investing in additional staffing in maternity to the value of £500k to strengthen leadership and governance to support safe care. I hope that this response demonstrates that the Trust are committed to learning from Mrs Walker's death and to improving care for our future patients. Yours sincerely Chief Executive 2
See every Prevention of Future Deaths report matching Hospital Death (Clinical Procedures and medical management) related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.