Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0261, written 20 Jul 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 Jul 2023 |
|---|---|
| Reference | 2023-0261 |
| Deceased | Elliott Harratt |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Child Death (from 2015) |
| 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Greater Manchester Integrated Care 1 CORONER I am Alison Mutch, Senior Coroner, for the Coroner Area of Greater Manchester South 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 1st February 2023 I commenced an investigation into the death of Elliott James Harratt. The investigation concluded on the 26th June 2023 and the conclusion was one of Natural causes. The medical cause of death was 1a Extreme Prematurity 4 CIRCUMSTANCES OF THE DEATH Elliott James Harratt's mother went into early labour with him. He was born at the family home and transferred to Tameside General Hospital. He was 20 plus 4 weeks gestation. He died at Tameside General Hospital on 29th January 2023 from extreme prematurity 5 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 my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – In the course of the inquest into Elliott’s death evidence was heard of a matter that did not contribute to his death but was of concern for the future for other babies. The inquest heard evidence that the rhesus status of Elliott’s mum meant that after a sensitising event Anti D needed to be given to prevent Rhesus disease in a newborn baby. The evidence before the inquest was that the type of events that would constitute a sensitising event and what action 1 was then required were not made clear to Elliott’s mum. In addition, the type of events where a call to maternity triage for advice were not made clear to his mum. This was, the evidence suggested, because there was no readily accessible or consistent list given to expectant mothers at booking in appointments or at follow up signposting them. Such a document in the form of a handout laminate or as a list in the handheld notes would increase awareness of events where a call to maternity triage would be advisable for health of both the mother and baby enabling health professionals to intervene at the earliest possible stage. 6 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. 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 September 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 namely 1) Tameside General Hospital, who may find it useful or of interest. on behalf of the Family; 2) 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 Alison Mutch HM Senior Coroner 20.07.2023 2
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.
E: mandy.philbin@nhs.net Date: 27th September 2023 Ms A Mutch HM Senior Coroner Coroner’s Court 1 Mount Tabor Street Stockport SK1 3AG Dear Ms Mutch, Re: Regulation 28 Report to Prevent Future Deaths Thank you for your Regulation 28 Report dated 20th July 2023 concerning the sad death of Elliott James Harratt on the 29th of January 2023. On behalf of NHS Greater Manchester Integrated Care (NHS GM), We would like to begin by offering our sincere condolences to Mr Harratt’s family for their loss. Thank you for highlighting your concerns during baby Harratt’s Inquest which concluded on the 26th of June 2023. On behalf of NHS GMICB, we apologise that you have had to bring these matters of concern to our attention. We recognise it is very important to ensure we make the necessary improvements to the quality and safety of future services. Following the inquest, you raised concerns in your Regulation 28 Report to NHS GM that there is a risk a future death will occur unless action is taken. The medical cause of death was Extreme Prematurity. I hope the response below demonstrates to you and baby Harratt’s family that NHS GM has taken the concerns you have raised seriously and will learn from this as a whole system. This letter addresses the issues that fall within the remit of NHSGM and how we can share the learning from this case. The inquest heard evidence that the rhesus status of Elliott’s mum meant that after a sensitising event Anti D needed to be given to prevent Rhesus disease in a newborn baby. The evidence before the inquest was that the type of events that would constitute a sensitising event and what action was then required were not made clear to Elliott’s mum. In addition, the type of events where a call to maternity triage for advice were not made clear to his mum. This was, the evidence suggested, because there was no readily accessible or consistent list given to expectant mothers at booking in appointments or at follow up signposting them. Such a document in the form of a handout laminate or as a list in the handheld notes would increase awareness of events where a call to maternity triage would be advisable for health of both the mother and baby enabling health professionals to intervene at the earliest possible stage Every patient is offered an ultrasound scan at around 10 to 14 weeks of pregnancy. This is called the dating scan. It's used to see how far along the patient is in their pregnancy and check the baby's development. The scan may also be part of a screening test for Down's syndrome. 4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk There is a second (anomaly) scan at 18-21 weeks where they check for structural abnormalities in the baby. Further scans can be offered depending on health and pregnancy. At these appointments the clinicians discuss any potential risks such as the mother having D blood type (previously known as “Rhesus D”, “RhD” or “Rhesus”), and it is also an opportunity to answer any questions and provide both verbal and written information in relation to what to do if there are any concerns about the baby or the mother. If a mother has D blood type, this is discussed at the 18-21 week scan to ensure that the mother is aware of their status. They are also given written information on this. The written information is produced by NHS Blood and Transplant: • Blood Groups and Red Cell Antibodies in Pregnancy – NHS Blood and Transplant leaflet https://nhsbtdbe.blob.core.windows.net/umbraco-assets-corp/18055/inf166-blood-groups-and- red-cell-antibodies-in-pregnancy.pdf • Protecting women and babies with anti-D Immmunoglobulin – NHS Blood and Transplant leaflet https://www.bfwh.nhs.uk/wp-content/uploads/2015/08/inf1300.pdf Each of our Trusts in Greater Manchester that provide maternity services are set up slightly differently in relation to how they deliver services, however the advice they provide to mothers on when to contact services is consistent across the system and comes in many forms, written, verbal and online. We will use this event as an opportunity to highlight the importance of ensuring that mothers who do have D blood type, have the appropriate guidance, written information and understand when to contact services. Actions taken or being taken to share learning across Greater Manchester: 1. Learning to be presented/shared with the Greater Manchester System Quality Group on the 16th of November 2023. This meeting is attended by a broad range of system leaders including clinical and care leaders, commissioners of specialist services, locality representatives from each of the 10 GM boroughs, the CQC, Healthwatch who represent the public voice and NICE. Through sharing in this forum, we expect members to review and ensure learning is incorporated into their commissioned services. 2. As part of our approach to embedding the learning we share the learning from this and similar cases at Greater Manchester and borough level. This is cascaded to professionals through relevant governance and learning forums to ensure that learning is incorporated into their services. In this case it will be discussed at the Local Maternity and Neonatal Network Safety Assurance Panel on the 5th of October 2023. In conclusion, key learning points and recommendations will be monitored to ensure they are embedded within practice. NHS GM is committed to improving outcomes for the population of Greater Manchester. We hope this response demonstrates to you and baby Harrat’s family that NHS GM has taken the concerns you have raised seriously and is committed to working together as a system including our service users, carers and families to improve the care provided. Thank you for bringing these important patient safety issues to our attention and please do not hesitate to contact us should you need any further information. 4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk Yours sincerely Mandy Philbin Chief Nursing Officer GM Integrated Care Sandra Stewart Place Based Lead Tameside GM Integrated Care 4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk 4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk
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