Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0344, written 16 Sep 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 Sep 2023 |
|---|---|
| Reference | 2023-0344 |
| Deceased | Sienna Monterio |
| Coroner | Alan Wilson |
| Coroner area | Blackpool & Fylde |
| Category | Child Death (from 2015) |
| Organisation named | Blackpool Teaching Hospitals NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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:
1. The Royal College of Obstetricians and Gynaecologists
10-18 Union Street,
London Bridge,
SE1 1SZ
2. The Royal College of Paediatrics and Child Health
5-11 Theobald’s Road
London
WC1X 8SH
3. NICE – National Institute for Health and Care Excellence
National Institute for Health and Care Excellence
Level 1A, City Tower
Piccadilly Plaza
Manchester
M1 4BT
1
CORONER
I am Alan Anthony Wilson Senior Coroner for Blackpool & Fylde
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.
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
3
INVESTIGATION and INQUEST
The death of Sienna Scarlett Monterio, on 6th April 2022 at Blackpool Victoria Hospital was
reported to me and I opened an investigation, which concluded by way of an inquest on 15th
September 2023.
I determined that the medical cause of Sienna’s death was 1 a 1 a Fetal-maternal
haemorrhage
In box 3 of the Record of Inquest I recorded as follows:
Sienna Monteiro was born in hospital in Blackpool on 6th April 2022. Earlier that morning, her
Mother rang the hospital to report a lack of fetal movements and was appropriately asked to
attend the maternity day unit, arriving within 30 minutes.
There had been no noticeable fetal movements since the previous evening. It is likely that a
fetal-maternal haemorrhage had occurred during the previous afternoon or early evening,
and at around the time her Mother was admitted to hospital Sienna would have been
experiencing some mild hypoxia.
Upon being triaged, and with a concerning CTG trace, plans were made for Natalie to go the
delivery suite for continued observations. Sienna was delivered by way of an emergency
caesarean section at 10.18 hours. Sienna was pale and was handed to the neonatal team and
she was given ventilation breaths. A Consultant Paediatrician attended when Sienna was four
minutes old. Sienna remained on the delivery unit so she could be stabilised prior to her
transfer to the neonatal unit for ongoing care, which would have included establishing IV
access through an umbilical cord catheter. There were difficulties in trying to intubate Sienna.
At around 77 minutes of age, there was no detectable heart rate. CPR was commenced but
after 20 minutes of resuscitation with no cardiac output, this was stopped when there were
no apparent signs of life and death was confirmed at 11.59 hours that morning. A
subsequent paediatric post – mortem report revealed Sienna died due to a severe fetal –
maternal haemorrhage, which occurs when there is a passage of fetal blood into the
maternal circulation. Prior to Sienna being born, there had been no clear indication of a fetal
– maternal haemorrhage. In part due to what appeared to be effective lung inflation, and a
reassuring heart rate, the extent of fetal compromise was not fully appreciated. Sienna
suffered a delayed collapse from which she could not be resuscitated, caused by significant
blood loss and hypoxia. The blood loss needed to be replaced if she was to respond to
ventilation. This fetal – maternal haemorrhage was a very rare occurrence as there had been
incomplete haemodynamic recovery by the time Sienna was born. Given the circumstances
at the time, there was nothing the clinical team could have done to avoid the fatal outcome.
In addition to the above, I wish to note that I made the following findings:
That investigation revealed no significant failings in the antenatal care received, nor in
relation to the obstetric care provided;
That earlier attendance at the hospital once a reduction in felt movement was
suspected would not have altered the outcome;
In box 4 of the Record of Inquest I determined that Sienna died due to:
Natural causes
4
CIRCUMSTANCES OF THE DEATH
In addition to the contents of section 3 above, the following is of note:
In advance of the inquest, the court received a maternity investigation report from the
Healthcare Safety Investigation Branch [HSIB] which included the following finding:
“Paired cord blood gas samples were taken at the time of birth of the Baby. The blood gas
analyser was not set to analyse the haemoglobin. This prevented other possible causes for the
Baby’s condition being considered and possibly corrected.”
At the end of that report, this recommendation was made:
“The Trust to ensure a blood gas analyser with an Hb (haemoglobin) measurement facility is
available in all neonatal resuscitation settings to support the provision of clinical information,
and to optimise decision making processes and clinical care.”
Despite the fact that in Sienna’s case I found that it did not contribute to her death,
nevertheless, having considered the evidence received at inquest, I have a concern that this
issue may pose a risk in future.
Haemoglobin is the protein in red blood cells that carries oxygen to the body's organs and
tissues. If a blood test reveals that haemoglobin levels are lower than normal this is known as
anaemia.
[independent Obstetrics & Gynaecology witness] told the court that
although in his experience the blood gas analyser facility is usually turned on, he had recently
been involved in a significant piece of work analysing maternity incidents within another
hospital trust and found that it is variable whether this function is turned on or not;
[independent Consultant Neonatologist] echoed
comments, and said he that rather than having to rely on clinical observation only, were
clinicians to have this blood gas analyser data in the event of a low haemoglobin level in the
blood cord gas, this may provide additional insight. He went on to say that personally, he could
see no potential disadvantage in having the Hb measurement being readily available in the cord
blood gas from a clinical perspective;
The court also received some helpful information from Blackpool Teaching Hospitals NHS
Foundation Trust on this issue which included the following:
that cord blood haemoglobin analysis is not a standard requirement and does not form
part of the Newborn Life Support (NLS) process;
that according to guidance from The British Journal of Haematology, the current
position is that cord blood testing is not regulated or included in the Newborn Life
Support (NLS) process at a national level and that there remain concerns regarding the
reliability of samples tested by the blood gas analyser;
that against this background nationally, from a local perspective the Trust in Blackpool
are considering whether there may be steps that can be taken locally, despite there
being no national requirement for the same, to use cord blood sampling as a screening
tool to assist in ongoing treatment. The Trust add they are acutely conscious that no
snap decision should be made and that careful consideration is given to the matter
such that the Trust can be reassured that any changes made locally are both safe and
appropriate in the clinical setting. As Senior Coroner for this coroner area, I regard that
approach as reassuring.
However, having considered all of the above, I have determined that I have a duty to write this
report.
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 could occur unless action is taken. In the
circumstances it is my statutory duty to send the report:
The MATTER OF CONCERN is as follows. –
I have conducted a complex inquest into the death of newborn baby in a maternity setting. The
evidence included input from independent expert witnesses, senior consultant paediatricians
from the hospital trust.
Having reviewed the circumstances surrounding Sienna’s death, the Healthcare Safety
Investigation Branch [HSIB] found that at the time of birth the blood gas analyser was not set to
analyse the haemoglobin level.
The HSIB very clearly state that in the absence of this data, this “prevented other possible
causes for the Baby’s condition being considered and possibly corrected.”
The HSIB has also recommended this facility is available in all neonatal resuscitation settings to
support the provision of clinical information, and to optimise decision making processes and
clinical care.
Sienna was born following an urgent caesarean section, and died within two hours of delivery.
Those who work in this area inevitably have to make urgent, life-saving decisions and in the
most challenging of circumstances, and it seems to me that there is a lack of clarity on this issue
which needs to be addressed. In the absence of such clarity, a baby may die from a preventable
cause which is not appreciated by clinicians in the absence of data which would have
highlighted a low haemoglobin level in the blood cord gas.
It appears that in some trusts, this data will be readily available, but not in others. If
comment above is correct, there may be different practices within the one trust.
The court has been told that cord blood testing is not regulated or included in the Newborn Life
Support (NLS) process at a national level. It appears as though the hospital trust in Blackpool is
considering this issue appropriately, and this may reflect the picture nationally.
The HSIB states this data may assist in identifying other possible causes for a baby’s condition
being considered, and possibly corrected.
expresses the view that he sees no
potential disadvantage in having the Hb measurement being readily available in the cord blood
gas from a clinical perspective. I have therefore concluded that there is risk of future deaths
and that I therefore have a duty to write this report.
I do not seek to be prescriptive about what should now happen, and that is not the purpose of
this report. I simply raise the concern. It may be the recipients of this letter feel the issue is one
which is being addressed , but it would be remiss of me not to raise this concern should
Sienna’s inquest provide assistance.
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. Given
the approaching holiday period I have extended this period to 12th November 2023. I, the
coroner, may extend the period further.
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:
The Director of North West Neonatal Operational Delivery Network
Medical Director of Blackpool Teaching Hospitals NHS Foundation Trust.
[Parents of Sienna]
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
16/09/2023
Signature__________
Alan Anthony Wilson Senior Coroner Blackpool & Fylde
_______________
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