Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0228, written 30 Jun 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 30 Jun 2023 |
|---|---|
| Reference | 2023-0228 |
| Deceased | Sinon Masha |
| Coroner | Emma Brown |
| Coroner area | Birmingham and Solihull |
| Category | Child Death (from 2015) |
| Organisation named | University Hospitals Birmingham NHS Foundation Trust |
| 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
THIS REPORT IS BEING SENT TO:
University Hospitals of Birmingham NHS Foundation Trust
CORONER
I am Emma Brown, Area Coroner for Birmingham and Solihull
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.
INVESTIGATION and INQUEST
On 30 December 2021 I commenced an investigation into the death of Sinon MASHA. The
investigation concluded at the end of the inquest. The conclusion of the inquest was:
Natural causes.
CIRCUMSTANCES OF THE DEATH
Sinon Masha was born following a home birth at 13:41 on the 17th December 2021. For a
variety of reasons, a home birth was against medical advice, this had been explained on a
number of occasions throughout the pregnancy. On the 17th December 2021 advice to
transfer to hospital had been given by midwives during early labour due to concerns that
Sinon's mother was showing signs of pre-eclampsia and due to findings of light meconium
staining on rupture of membranes which could indicate fetal distress. This advice was not
accepted. At 12:47 it was identified that Sinon maybe an undiagnosed breech presentation,
transfer to hospital was recommended and declined. Up to that time presentation based on
abdominal palpitation and vaginal examinations had been assessed as cephalic. A frank
breech presentation was confirmed during a 999 call commencing at 13:00. Paramedics
arrived at scene at 13:07 and transfer to hospital was again advised and not accepted. The
presenting part delivered at 13:14, there was then a 27 minute period before delivery of
Sinon's head causing a catastrophic hypoxic brain injury. He received resuscitation and
was transferred to Birmingham Heartlands Hospital arriving at 49 minutes of age. At 57
minutes Sinon was found to have a heartbeat, he was ventilated and cooled but remained
comatose and subsequently developed signs of encephalopathy and multi organ failure, a
decision was made to provide palliative care on the 20th December and Sinon died at 05:15
on the 21st December 2021.
Based on information from the Deceased’s treating clinicians the medical cause of death was
determined to be:
1a Hypoxic ischaemic encephalopathy
1b Undiagnosed breech presentation during home delivery
1c
II
CORONER’S CONCERNS
During the course of the inquest 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
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my statutory duty to report to you.
The MATTERS OF CONCERN are as follows. –
1. The University Hospitals of Birmingham NHS Foundations Trust (‘UHB’) has specific
guidance covering home birth against medical advice in the form of ‘Birth Choices
Guidance, CG1200, June 2021’ and ‘Homebirth Including Risk Assessment, CG1143,
August 2021’.
2. Specifically, Section 5 of the Birth Choices Guidance includes:
“5.1 All women requesting birth outside of guidance must be referred for discussion to the
consultant midwife via BadgerNet for decision-making regarding their birth choices.
….
5.7. Where there are complexities that require the input of other professionals and if the
woman remains undecided or voices a decisive choice to pursue a plan outside of
Trust guidance a joint multiprofessional appointment must be arranged.
5.8. This appointment should include the consultant midwife; the woman’s named
obstetric consultant and other relevant professionals/clinicians as needed. The
consultant midwife will convene the multiprofessional team meeting with the purpose
of ensuring that a comprehensive multiprofessional pregnancy and birth plan is
formulated.
5.9. There may be occasions when the multiprofessional team cannot meet. In these
circumstances it is acceptable for the multiprofessional team to see the woman
separately. However, the team members must still agree a plan together and
document this on the woman's records.”
3. Evidence given at the inquest pertaining to the current situation was that the system
outlined in section 5.8 of the Birth Choices Guidance is not in operation at all. Evidence
was given by UHB’s Community Matron that without the input of a Consultant Obstetrician
at the multiprofessional appointment, things might be missed in the birth plan, and the
information given by the Consultant Midwife and Community Midwives may not carry the
same weight with the patient as hearing the opinion of the Consultant Obstetrician. It was
stated in evidence by the Community Matron that this could put the lives of Mums and
babies at risk.
4. Evidence was given by the Director of Midwifery that although patient’s named Consultants
are not involved in multiprofessional appointments with the patient there is a bi-weekly
meeting of the other professionals who discuss all high risk patients and then the
Consultant midwife meets with the patient’s named Consultant (who will have reviewed the
patient in clinic) and discusses the individual cases and the birth plans. This system is felt
to be working satisfactorily by the Consultant midwife.
5. I remain concerned that the current approach has evolved from necessity rather than being
a carefully considered and planned amendment to the Trust’s guidance. Furthermore, the
approach appears fragmented increasing the risk of mis-communication or mis-
understanding. This system also deprives the patient of the benefit of hearing the
perspectives of all the relevant professionals together in a setting where they, the patient,
can witness the discussion and be satisfied that everyone has considered all the relevant
factors and answered any queries or concerns they may have relevant to their decision.
Consequently, I am concerned that patients may not be making fully informed decisions
resulting in birth choices that put lives at risk.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you have the power to
take such action.
YOUR RESPONSE
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You are under a duty to respond to this report within 56 days of the date of this report, namely by
30 August 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.
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:
West Midlands Ambulance Service and the HSIB.
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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.
30 June 2023
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Signature:
Miss Emma Brown
HM Area Coroner
for Birmingham and Solihull
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.
30 August 2023 For the attention of Miss Emma Brown Area Coroner for Birmingham and Solihull Birmingham Coroner’s Court 50 Newton Street Birmingham Dear Miss Brown Inquest touching the death of Sinon Masha Response to Regulation 28 Report to prevent future deaths I write in response to the Regulation 28 Report made by you following the Inquest touching the death of Baby Masha which concluded on 29 June 2023. University Hospitals Birmingham NHS Foundation Trust (the Trust) has carefully considered the concerns raised within your report to prevent future deaths, which relate to the Trust’s Birth Choices Guidance, specifically section 5 and that ‘patients may not be making fully informed decisions resulting in birth choices that put lives at risk’. At the time Ms Masha (mother) was under the care of the Trust there was a Consultant midwife vacancy on-going for 2 months and normally they would be responsible for developing the birth plans. In their absence the responsibility for developing the birth plans was the Matron for Community. Matron Adams (Matron for Community) developed the birth plan for Ms Masha, which was complicated because she was a late transfer from another Trust. At the time Ms Masha was under the care of the Trust, the Trust’s Birth Choice Guidelines states under 5.9 ‘Where there are complexities that require the input of other professionals and if the woman remains undecided or voices a decisive choice to pursue a plan outside of Trust guidance a joint multi-professional appointment must be arranged’. The process for MDT discussion was in place although due to the pandemic this was sometimes held as separate discussions. The birth choices guideline does give flexibility for this to occur in section 5.11 it states ‘there may be occasions when the multi professional team cannot meet. In these circumstances it is acceptable for the multi professional team to see the woman separately. However, the team members must still agree a plan together and document this on the woman's records.” Due to her late transfer of care, and having missed her initial consultant appointment, the birth plan was sent to the initial booking consultant for agreement via email. Ms Masha had a subsequent telephone appointment with another consultant but delivered the following day before the telephone appointment could take place. Following Baby Masha’s death the following actions have been taken: There are now two consultant midwives in post who share the birth choices discussion and planning for women requesting homebirth outside of guidance. A Bi-weekly MDT meeting is in place with joint discussion and planning separately with the named consultant. To ensure compliance with the standards an audit is in place to evidence multidisciplinary input for high-risk home births. The initial audit has demonstrated that for those women who had requested birth outside of guidance, there was always consultant input into their birth plan. There is a plan to agree allocated Consultant (either Delivery suite lead or Antenatal clinic lead) to regular MDT meetings. This is contingent on the current consultant job planning (due for completion by 31 August 2023). Following job planning this action will be completed before the 31 October 2023. A review of the Birth Choices Guidelines (CG1200) and the home birth guidance (CG1143) is being undertaken and will be completed by 31 October 2023. Currently there are discrepancies in relation to the referral pathway, roles and responsibilities of members of the multi-professional team (including Consultant Midwife), and inclusion of the woman in birth planning discussions. Alignment of these guidelines will provide a clear and standardised pathway for referral and management for women/birthing people requesting birth outside of guidance including homebirth, and clarity of Roles and responsibilities of each member for the Multi professional team. I would like to reassure you that the concerns raised within the Regulation 28 Report have been taken extremely seriously which I hope is demonstrated by our response above. Yours sincerely Chief Executive Officer CC , Chief Nurse Head of Clinical Governance and Patient Safety Director of Midwifery
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