Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0127, written 20 Apr 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 Apr 2023 |
|---|---|
| Reference | 2023-0127 |
| Deceased | Chester Mossop |
| Coroner | Kirsty Gomersal |
| Coroner area | Cumbria |
| Category | Child Death (from 2015) · Product related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
KALLY CHEEMA SENIOR CORONER County of Cumbria Fairfield Station Rd Cockermouth, CA13 9PT REGULATION 28 REPORT TO PREVENT FUTURE DEATHS CHESTER ALAN STANLEY MOSSOP aged 9 MONTHS THIS REPORT IS BEING SENT TO: NATIONAL HEALTH SERVICE OFFICE OF PRODUCT SAFETY AND STANDARDS 1 CORONER I am Miss Kirsty Gomersal Area Coroner for County of Cumbria 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: https://www.legislation.gov.uk/ukpga/2009/25/contents http://www.legislation.gov.uk/uksi/2013/1629/contents 3 INVESTIGATION and INQUEST Chester Alan Stanley MOSSOP died on 3 June 2022 following an incident at his home address on 29 May 2022. Baby Chester’s death was reported to HM Coroner for Cumbria on 6 June 2022 and his death formally transferred from HM Coroner Newcastle. An investigation into his death (in accordance with Section 1 Coroners and Justice Act) was commenced on the same day. An inquest into Chester’s death was opened on 23 February 2023 and his inquest was heard before me on 13 April 2023. The medical cause of Chester’s death was: 1a Hypoxic ischaemic brain injury 1b Cardiac arrest (resuscitated) 1c Drowning The determination was: Chester Alan Stanley Mossop was a healthy and well-looked after 9 months' old baby. On 29 May 2022, Chester was placed in a bath seat in a bath of warm water at his home. After approximately 20 minutes of bath time, Chester was left alone in his bath seat. After a few minutes, Chester was found face down in the bath, the bath seat having become unfixed. Chester was given immediate CPR which was continued by attending police, paramedics and clinicians. Chester was conveyed to the Great North Children's' Hospital at the Royal Victoria Infirmary by air ambulance. Everything was done to try to save Chester's life. However, an MRI scan showed that Chester had sustained an unsurvivable brain injury due to drowning and he died in his mother's arms on 3 June 2022 at 18:05 at the Royal Victoria Infirmary. The conclusion of the inquest was: Accidental Death I rejected, giving full reasons, a submission that Chester’s death was due to neglect and I made no finding in that respect. I rejected, giving full reasons, a submission that Chester’s death was due to unlawful killing (by gross negligence manslaughter). 4 CIRCUMSTANCES OF THE DEATH Chester was a healthy and well looked after 9 months’ old baby. He was usually fit and well. However, on 29 May 2022, he had a mild viral infection (which was confirmed at post-mortem). Chester was placed in a bath seat and given a bath in suitably warm water. The water level was higher than advised - so that Chester did not get chilled. After about 20 minutes of bath time, Chester was left alone in his bath seat whilst a plug- in diffuser (to help his cold) was prepared in his bedroom. It was believed that the bath seat was safe and secure to hold him in place. After a few minutes, Chester was found face down in the bath. The bath seat had become unfixed. There were no sounds that Chester was in distress or difficulty. He was immediately removed from the bath and given immediate CPR by a trained adult. Emergency services were quickly on scene and CPR was continued by police, paramedics and clinicians. Return of spontaneous circulation was achieved. Chester was flown by air ambulance to the Great North Children’s Hospital at the Royal Victoria Infirmary in Newcastle. However, an MRI scan undertaken on 2 June 2022 showed that Chester had an extensive severe brain injury consistent with severe global hypoxic ischaemia caused by drowning. It was considered that Chester was unlikely to survive and further intensive care treatment was not in his best interest. Intensive care support was withdrawn on 3 June 2022 and Chester died peacefully in his mother’s arms at 18:05. I received a statement from RoSPA (the Royal Society for the Prevention of Accidents) setting out that: • Baby bath seats are unstable and prone to toppling over leaving the baby trapped in the water. • Bath seats may give parents and carers a false sense of security that baby is safer in a bath seat and can be left alone (despite warnings that this should not happen). There can be a misconception that a baby bath seat is a safety product – this is not the case. • • Under no circumstances should parents regard bath seats as a safety aid and leave a child out of arms reach. • RoSPA is aware of incidents where parents have been in the room, but away from the baby, with tragic results. • RoSPA is aware of a number of drownings of young children in the bath where a • baby bath seat has been used. There may be some bath seats that are less stable than others or that have inadequate methods to hold them in place. I heard no evidence about any safety concerns with the bath seat in question. The Child Death Overview Panel (“CDOP”) advised me that a Bath Safety Alert had been issued in the North-East and North Cumbria. This can be viewed at: www.nenc-healthiertogether.nhs.uk/parentscarers/keeping-your-child-safe/bath-safety- advice I requested an update on several matters but these were not available at the date of Chester’s inquest. Given the “ancillary nature” of Reports to Prevent Future Deaths and to avoid the distress of an adjournment to Chester’s family, I decided to proceed with the inquest. 5 CORONER’S CONCERNS The evidence revealed matters giving rise to concern. In my opinion 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: I am aware of similar tragic deaths to Chester’s and inquests held by my fellow Coroners. RoSPA is also aware of fatal and non-fatal incidents. The use of bath seats is of concern to RoSPA. Whilst I am aware of the regional Bath Safety Advice (set out above), I am not aware that similar advice has been distributed on a national level to healthcare professionals and to parents / carers. I am not aware whether parents / carers are provided with advice about the safe use of bath seats as part of e.g. health visits. I am concerned that bath seats may given parents a false sense of security that their child is safe. Bath seats are not safety devices. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe the NATIONAL HEALTH SERVICE OFFICE OF PRODUCT SAFETY AND STANDARDS has 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 16 June 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: Chester’s family. I have also sent copies to: RoSPA National Child Mortality Database Child Death Overview Panel I am also under a duty to send the Chief Coroner a copy of your response. 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 this 20th day of April 2023 Miss Kirsty J Gomersal HM Area Coroner County of Cumbria
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.
Kirsty Gomersal
HM Coroner’s Office
Fairfield
Station Road
Cockermouth
Cumbria
CA13 9PT
Dear Ms Gomersal
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
3 July 2023
Re: Regulation 28 Report to Prevent Future Deaths – Chester Alan Stanley
Mossop who died on 3 June 2022.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 20 April
2023 concerning the death of Chester Alan Stanley Mossop who died on 3 June 2022.
In advance of responding to the specific concerns raised in your Report, I would like
to express my deep condolences to Chester’s family and loved ones. NHS England
are keen to assure the family and the coroner that the concerns raised have been
listened to and reflected upon.
I am grateful for the further time granted to respond to your Report, and I apologise for
any anguish this delay may have caused Chester’s family. I realise that responses to
Coroner Reports can form part of the important process of family coming to terms with
what has happened to their loved ones and appreciate this will have been an incredibly
difficult time for them.
Your Report raised that the use of bath seats for babies is a concern to the Royal
Society for the Prevention of Accidents (RoSPA) and that their use can give parents a
false sense of security. You raised the concern that you were not aware if the advice
from RoSPA had been distributed on a national level to healthcare professionals and
to parents/carers, and whether parents/carers were provided with advice about the
safe use of bath seats.
We were very saddened to hear about this case which has been carefully considered
by colleagues across the organisation including from Patient Safety, Maternity and
Children and Young People teams. In response to the concerns raised, NHS England
will be updating its ‘Washing and bathing your baby’ website page to include guidance
on the use of bath seats for babies. This will make clear that bath seats for babies are
not recommended for use by RoSPA or by the Child Accident Prevention Trust
(CAPT), who we have engaged with on this matter, and that they are not safety
devices. The update to the website will also include text to raise awareness with
parents/carers that babies can drown within seconds, in just a few centimetres of water
and with no noise or struggle and reemphasise that babies of any age should always
be kept at arm’s reach of an adult whenever they are in the bath. These updates to
the website are moving through NHS England’s internal approval process and are
expected to be made imminently. We are happy to advise you as soon as these
updates have been made.
This advice will also be incorporated into staff bulletins for midwifery and healthcare
workers, reminding staff to communicate this important safety message to parents and
carers during their interactions. I am also aware that my Maternity colleagues are
picking up on the concerns raised with the Royal College of Midwives (RCM) and the
British Association of Perinatal Medicine (BAPM), to consider whether any further
awareness work can be implemented via their networks.
NHS England will also be sharing the case through Patient Safety bulletins and will
discuss at our next national Regulation 28 Working Group meeting in August.
Regional colleagues who sit on the Working Group membership will be asked to
ensure that the safety message around bath seats is shared to their systems, to help
raise further awareness.
We have discussed this case and the concerns raised with colleagues at the Office for
Health Improvement and Disparities (OHID) at the Department of Health and Social
Care and are advised that they will be raising the case with their networks as a safety
alert.
The National Child Mortality Database (NCMD) will also shortly be publishing a
thematic report on deaths of children and young people due to traumatic incidents
between April 2019 and April 2023, which will include drownings. Many of the
drownings considered within the scope of the report did take place when a child or
baby had been left unsupervised. As advised above, NHS England are undertaking a
communications push to highlight the importance of never leaving babies of any age
unsupervised while in the bath. We will also of course consider any additional
recommendations made by the NCMD within its report.
NHS England has been sighted on the response to your Report from the Office for
Product Safety and Standards (OPSS) and I am pleased to hear that the OPSS will
also be assessing the safety and compliance with legal requirements of similar models
of baby bath seats to the one used by Chester, and that they will take any relevant
action.
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
Office for Product Safety and Standards 1 Victoria Street Westminster London SW1H 0ET General enquiries: +44 (0)121 345 1201 15/06/2023 Miss Kirsty Gomersal HM Area Coroner County of Cumbria Fairfield Station Rd Cockermouth, CA13 9PT Dear Miss Kirsty Gomersal, Thank you for your Regulation 28 Report (Prevention of Future Deaths) dated 20 April 2023, following your investigation and inquest into the death of Chester Allan Stanley Mossop. First, I would like to say how deeply saddened I was on hearing of the tragic death of baby Chester. I would be grateful if you could pass on my condolences to the family if you have the opportunity to do so. The Office for Product Safety and Standards (OPSS) is the UK’s national product regulator. The UK has a product safety system designed to provide a high level of protection for consumers and all consumer products including baby bath seats, must be safe before they can be sold on the UK market. The safety of baby products is a priority area for OPSS and we have recently taken action to prevent the sale of a number of unsafe baby products including baby self-feeding devices. Baby bath seats are regulated under the General Product Safety Regulation 2005 (GPSR). This places an obligation on manufacturers or importers to ensure their products are safe before they can be placed on the market (Regulation 5 of GPSR). They must also provide safety information to enable consumers to assess risks that are not immediately obvious without adequate warnings and to take precautions against those risks (Regulation 7 of GPSR). Distributors have a separate duty to act with due care to ensure that products they offer for sale comply with the law; are safe; and to pass on the necessary information on the risks posed by the product (Regulation 8 of GPSR). The Office for Product Safety and Standards is part of the Department for Business and Trade. We strive to enhance protections for consumers and the environment and drive increased productivity, growth and business confidence. https://www.gov.uk/government/organisations/office-for-product-safety-and-standards Since receiving your Report, OPSS has been in contact with your office to obtain further details of the product involved in this incident. As a result, OPSS will be assessing the safety and compliance for similar models of baby bath seat to assess their compliance with legal requirements. While we do not currently have any evidence that the product itself is unsafe or non-compliant, should that be identified, we have a range of actions open to us to ensure products are brought into compliance or removed from the market. We will also work with the Baby Products Association (BPA), the relevant trade association for the sector, to ask them to remind their members of the requirements for including appropriate instructions for safe use and to ensure that any safety warnings for baby bath seats are suitably clear and prominent. We have worked closely with the National Health Service (NHS) on our programme of activity on the safety of baby products and will ask them to consider whether there is an opportunity to include safety messages related to baby bath seats through their communications with healthcare professionals and new parents. Thank you again for bringing this tragic case to our attention. Yours Sincerely, Deputy Chief Executive Office for Product Safety and Standards The Office for Product Safety and Standards is part of the Department for Business and Trade. We strive to enhance protections for consumers and the environment and drive increased productivity, growth and business confidence. https://www.gov.uk/government/organisations/office-for-product-safety-and-standards
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