deathlessons.org

Prevention of Future Deaths reports · 2023

Alfie Mains-Forster

Regulation 28 report to prevent future deaths, reference 2023-0459, written 9 Nov 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report9 Nov 2023
Reference2023-0459
DeceasedAlfie Mains-Forster
CoronerCrispin Oliver
Coroner areaCounty Durham and Darlington
CategoryChild Death (from 2015)
Sourcejudiciary.uk record · original PDF
Responses published1

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

Q 
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: 

1  The Directors of Clevermed Limited 

86-90 Paul Street 
3rd  Floor 
London 
EC2A 4NE 

2. The Chief Executive Officer of Clevermed Limited 

Clevermed 
Level 6, Edinburgh Quay 
133 Fountainridge 
Edinburgh 
EH3 9QG 

1  CORONER 

I am Crispin OLIVER, Assistant Coroner for the coroner area of County Durham and 
Darlington 

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 29/06/2022 13:30an investigation was commenced into the death of Alfie Neil MAINS-
FORSTER 13/06/2022. The investigation concluded at the end of the inquest on 09/11/2023 
14:51. The conclusion of the inquest was that Alfie died a natural death contributed to by 
neglect. 

4  CIRCUMSTANCES OF THE DEATH 

Alfie was born at 38+1 weeks at 01.35 on 13 June 2022 at the Royal Victoria Infirmary, 
Newcastle Upon Tyne. His mother had risk factors - gestational diabetes, a congenital heart 
condition and heightened blood pressure. At 4 minutes of age Alfie was noted as “grunting”. 
At 03.55 observations were documented on the NEWTT chart. Two were in the amber 
category - respiratory rate of 72 rpm and Oxygen saturation of 88%. The Mother was 
concerned and there was cyanosis around the mouth and nose. Intermittent grunting was 
noticed. At a review noted up at 5am, having probably occurred at around 04.30, saturation 
was 89.93%. On re-testing with a monitor from the resusitaire it was found to be 97%. The 
assessment found that there were no other signs of respiratory distress. The evidence from 
the Trust has included that given the maternal risk factors, once the two amber category 
observation at 03.55 had been documented, antibiotics should immediately have been 
administered to Alfie on a pre-emptive basis. In the event antibiotics were not applied, nor 
was close monitoring implemented. Alfie’s temperature fluctuated. At 05.15 he was 37.5 
degrees. By 14.00 he was 37 degrees. The fluctuation was to some extent influenced by 
environmental factors. He was noted as intermittently groaning at 06.30. There were 
complications with feeding. He underwent a tongue-tie procedure at 10.20. At 11.30 the 
complications were persisting. At around 16.45 Alfie was discharged home. He became 

Regulation 28 – After Inquest 
Document Template Updated 30/07/2021 

 increasingly unsettled, crying consistently. This worsened such that the parents called 999. 
Pre-alert to the Emergency Department of University Hospital of North Durham at 00.02 on 
14 June 2022 stated that Alfie was in cardiac arrest. Despite intensive treatment, and a 
brief return of cardiac output at 00.40, Alfie declined and died at 01.50. The medical cause 
of death provided following postmortem was 1)a) severe congenital pneumonia and 
meningitis, b) suspected acute chorioamnionitis. Reflecting the concession in the evidence 
of the Trust witnesses, the omission of antibiotics from 03.55 on 13 June 2022 is more 
likely than not to have contributed directly to Alfie’s death and, but for this omission, he 
would not have died. 

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: 
(brief summary of matters of concern) 

A)  In the badgernet electronic system used at the Royal Victoria Infirmary by the 

Newcastle Upon Tyne Hospitals NHS Foundation Trust, the current risk assessment 
(NEWS) does not map the national guidance fully and if would be more user-
friendly, and thereby assist towards more effective, and therefore safer, risk 
assessment for it to map the national guidance completely. 

B)  The current NEWTT2 chart is not yet available and it would assist in the more 

effective management of risk for it to be on BadgerNet.  This was supposed to be 
implemented in July 2023 but as yet it has not. 

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 January 04, 2024.  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 

I have also sent it to 

Consultant Neonatologist 
Royal Victoria Infirmary 
Queen Victoria Road 
Newcastle Upon Tyne 
NE1 4LP 

Regulation 28 – After Inquest 
Document Template Updated 30/07/2021 

 
 
 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: 09/11/2023 

Crispin OLIVER 
Assistant Coroner for 
County Durham and Darlington 

Regulation 28 – After Inquest 
Document Template Updated 30/07/2021

Responses

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.

Response from System Connecting Care (PDF) 
S C H -1 6 9  –  I n v e sti g ati o n  R e p o rt  

A ut h or:  

V er si o n:      

1. 5 

Cr e at e d:   

2 1 / 1 1 / 2 0 2 3  

U p d at e d:  

0 3 / 0 1 / 2 0 2 4 

Cl a s sifi c ati o n:   C O M M E R CI A L I N  C O N FI D E N C E  

R e g.  offi c e:  S y st e

m  C  H e alt h c ar e  Lt d,  Ar d e n  C o urt ,  Ar d e n  Str e et,  Str atf or d  u p o n  A v o n, 

W ar wi c k s hir e,  C V 3 7  6 N T 

 
 
 
 
 
 
 
 
 
 
 
 
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Pr o d u ct I nf or
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s u bj e ct t o  c h a n g e  a n d  a p pli c a bl e r e g ul at or y  a p pr o v al s. ©  C o p yri g ht  2 0 2 3,  S y st e
H e alt h c ar e  Lt d  

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m e nt t o 
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m  C 

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m ai n  at  S y st e

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m

D o c u

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N a

m e  

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2 9 / 1 1 / 2 0 2 3  

C o

m

m e nt  

A

m e n d

m e nt r e c or d  

I s s u e 
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V er si o n  

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V 0. 1  

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0 3 / 0 1 / 2 0 2 4  

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I nt er n al  c o pi e s f or r e vi e w  & 
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©  S y st e

m  C  H e alt h c ar e  Lt d  2 0 2 3                                                                 P a g e  2  of  1 0                                                     C O M M E R CI A L I N  C O N FI D E N C E  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Table of contents 
1 

Executive Summary .............................................................................................................................................................. 4 

2 

Investigation Methodology ............................................................................................................................................. 6 

2.1  Stakeholders ....................................................................................................................................................................... 6 

2.2  Roles & Responsibilities .............................................................................................................................................. 6 

2.2.1 

2.2.2 

2.2.3 

2.2.4 

2.2.5 

2.2.6 

Primary Investigator ................................................................................................................................ 6 

Investigator .................................................................................................................................................... 6 

Legal Counsel .............................................................................................................................................. 6 

Executive Sponsor .................................................................................................................................... 6 

Clinical Safety Officer ............................................................................................................................. 7 

Technical Authority .................................................................................................................................. 7 

2.3 

Investigation Plan ............................................................................................................................................................ 8 

3 

4 

Investigation Findings ......................................................................................................................................................... 9 

Improvements & Lessons Learnt ................................................................................................................................ 9 

4.1 

Implement NEWTT2 ..................................................................................................................................................... 9 

5 

References ................................................................................................................................................................................ 10 

© System C Healthcare Ltd 2023 

                                                              Page 3 of 10                                                    COMMERCIAL IN CONFIDENCE 

 
 
 
 
 
 
 
 1  

E x e c uti v e  S u

m

m ar y  

A  c or o n er’ s r e p ort  w a s r e c ei v e d  o n t h e  2 1 st  of  N o v e
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i n t h e  c or o n er’ s r e p ort t h at r e q uir e d i n v e sti g ati o n: 

m b er  2 0 2 3  t h at r e q uir e d  a n i n v e sti g ati o n 

•  

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1.  
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3.  

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m ar y  

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m e nt  N E

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©  S y st e

m  C  H e alt h c ar e  Lt d  2 0 2 3                                                                 P a g e  4  of  1 0                                                     C O M M E R CI A L I N  C O N FI D E N C E  

 
 
 (cid:120)  Ensure the NEWS functionality is clearly distinguishable from UK national guidance 

by defining its full title of Newborn Early Warning Score. 

© System C Healthcare Ltd 2023 

                                                              Page 5 of 10                                                    COMMERCIAL IN CONFIDENCE 

 
 
 
 
 
 Investigation Methodology 

2 
2.1  Stakeholders 

The following stakeholders have been identified to complete the investigation. 

Name 

Role 

Primary Investigator 

Investigator 

Legal Counsel

Executive Sponsor 

Executive Sponsor 

Executive Sponsor 

Clinical Safety Officer 

Technical Authority 

Technical Authority 

Technical Authority 

Technical Authority 

2.2  Roles & Responsibilities 

2.2.1  Primary Investigator 

Accountable for directing the investigation, to act impartial and independent to ensure a 
thorough investigation is conducted. 

Accountable for the creation of an investigation methodology plan that is followed that 
defines the actions to be completed, expected deliverables, targets and measurements as 
required. 

Accountable for the identification of stakeholders with specific competency to assist in the 
investigation, to ensure stakeholders are clearly defined and what remit they have within the 
constraints of the investigation.  

2.2.2 

Investigator 

Responsible for performing specific activities during the investigation as directed by the 
Primary investigator.  

Responsible for ensuring investigations progress to agreed deliverables and evaluate the 
outputs. 

2.2.3  Legal Counsel 

Accountable for providing legal guidance during the investigation and support any actions 
that are required that have legal implications and therefore require special attention. 

2.2.4  Executive Sponsor 

Accountable for providing sponsorship to the investigation allowing autonomy for the 
investigation to be conducted without impedance, delegating authority for resource 
allocation to the Primary investigator. 

Responsible for providing support to the investigation for appropriate escalations when 
required from the Primary Investigator.  

© System C Healthcare Ltd 2023 

                                                              Page 6 of 10                                                    COMMERCIAL IN CONFIDENCE 

 
 
 
 
 
 
 
 
 
 
 
 
 2.2.5 Clinical Safety Officer

Accountable for providing clinical safety authority within the investigation. 

2.2.6  Technical Authority 

Accountable for providing technical investigation, defining the technical actions required to 
investigate and retrieve information relevant to the investigation. 

To perform analysis of technical information to support the outcome of the investigation. 

© System C Healthcare Ltd 2023 

                                                              Page 7 of 10                                                    COMMERCIAL IN CONFIDENCE 

 
 
 
 
 2. 3  

I n v e sti g ati o n  Pl a n 

m e n c e d  o n  T u e s d a y  2 1 st  of  N o v e

T h e i n v e sti g ati o n  c o
c or o n er’ s  r e p ort fr o
r e p ort t o t h e  c or o n er. T w o f a ct or s  w er e i d e ntifi e d i n t h e  c or o n er’ s r e p ort t h at r e q uir e d 
i n v e sti g ati o n: 

m
m l e g al  c o u n s el r e q uiri n g  a n i n v e sti g ati o n t o  b e  c o n d u ct e d t o  pr o vi d e  a 

m b er  2 0 2 3  aft er  e s c al ati o n  of  a 

•  

•  

W S)  d o e s  n ot 

m  u s e d  at t h e  R o y al  Vi ct ori a I nfir

m a p t h e  n ati o n al  g ui d a n c e f ull y  a n d if  w o ul d  b e 

I n t h e B a d g er n et  el e ctr o ni c  s y st e
m ar y  b y t h e 
N e w c a stl e  U p o n  T y n e  H o s pit al s  N H S  F o u n d ati o n  Tr u st, t h e  c urr e nt ri s k  a s s e s s
m or e  u s er-
( N E
fri e n dl y,  a n d t h er e b y  a s si st t o w ar d s 
m or e  eff e cti v e,  a n d t h er ef or e  s af er, ri s k 
a s s e s s
T h e  c urr e nt  N E
eff e cti v e 
m pl e
i

W T T 2  c h art i s  n ot  y et  a v ail a bl e,  a n d it  w o ul d  a s si st i n t h e 

m e nt  of ri s k f or it t o  b e i n  B a d g er n et.  T hi s  w a s  s u p p o s e d t o  b e 

m e nt e d i n  J ul y  2 0 2 3  b ut  a s y et it  h a s  n ot.  

m a p t h e  n ati o n al  g ui d a n c e  c o

m e nt f or it t o 

m pl et el y.  

m a n a g e

m or e 

m e nt 

m ati o n  a b o ut t h e  a d

T o  g at h er i nf or
w er e i n  u s e, 
 a c c e s s e d t h e  Cli ni c al  S u
t h e  d at e s  b et w e e n t h e  1 2t h of  J u n e  2 0 2 2  a n d t h e  1 4 t h of  J u n e  2 0 2 2.  T h e i n v e sti g at or 
c o nfir

m e d t h e  p ati e nt r e c or d  di d  n ot  e xi st i n t h e  s y st e

mi s si o n  of t h e  p ati e nt  a n d  u n d er st a n d  w h at  s y st e

m  b et w e e n t h e s e  d at e s.  

m

m ar y  pr o d u ct f or t h e  sit e  a n d filt er e d 

m s 

mi n e if t h e  Cli ni c al  S u

T o  d et er
t h e i n v e sti g ati o n r e q uir e d t h e  d et er
ti

m e  of  o c c urr e n c e  o n t h e  1 3t h of  J u n e  2 0 2 2 . 

m ar y  pr o d u ct 

m

m a p s  t o t h e N H S  E n gl a n d  n ati o n al  g ui d a n c e, 

mi n ati o n  of t h e  pr o d u ct  a n d f u n cti o n ali t y i n  u s e  at t h e 

mi n e  w h at  pr o d u ct s  w er e  d e pl o y e d  at t h e ti

T o  d et er
e n g a g e d 
  a s t h e t e c h ni c al  a ut h orit y f or  d e v el o p
n ot e s t o  u n d er st a n d  w h at  v er si o n s  a n d f u n cti o n alit y  h a d  b e e n  d e pl o y e d t o t h e  sit e  a n d 
w h e n.  

m e  of t h e i n ci d e nt t h e i n v e sti g ati o n 

m e nt. H e  r e vi e w e d r el e a s e 

C o ntr a ct s  w er e r e vi e w e d  f or t h e  d eli v er y of  M at er nit y  a n d  N e o n at al
pr oj e ct  d eli v er a bl e s  a gr e e d  wit h t h e  c u st o
2 0 2 3.   

m er f or  G o  Li v e s  of  M at er nit y  a n d  N e o n at al i n 

 E P R  pr o d u ct s  wit h t h e 

mi n e  w h at  f u n cti o n alit y  w a s  wit hi n t h e d e pl o y e d  pr o d u ct s  at t h e ti

T o  d et er
i n ci d e nt, t h e i n v e sti g ati o n  e n g a g e d 
t e c h ni c al  a ut h orit y. T h e f u n cti o n alit y  of t h e  pr o d u ct  w a s  d e
w h et h er  N E

W S  a n d / or  N E

m e  of t h e 
 a s t h e  pr o d u ct  cli ni c al  s p e ci ali st  
mi n e 

m o n str at e d  t o  d et er

W T T  w a s i n cl u d e d  i n t h e  pr o d u ct t o t h e i n v e sti g at or s.    

T o  d et er

mi n e if t h e  N e o n at al  E P R  a n d  M at er nit y  pr o d u ct 

m a p s t o  n ati o n al  g ui d a n c e,  

a s s e s s e d t h e  N e o n at al  E P R  a n d  d et er
m a p t o  n ati o n al  g ui d a n c e  a n d  N e w b or n  E arl y 

d o e s 
f u n cti o n alit y i s i n cl u d e d a n d 
t o  u s e  eit h er  or  b ot h f u n cti o n s.  T h e  c u st o
c a n n ot  u s e t h e s e  wit hi n t h e  N e o n at al  E P R  pr o d u ct  c urr e ntl y.  

mi n e d  N E

m a p s t o  N e w  Z e al a n d  n ati o n al  g ui d a n c e.   C u st o

W ar ni n g  S c or e  ( N E

W T T f u n cti o n alit y i s i n cl u d e d  a n d 
W S –  N e w  Z e al a n d)  
m er s  c a n  el e ct 

m er  d o e s  n ot  h a v e  eit h er  e n a bl e d , t h er ef or e 

T o  d et er
N E
( N E
C u st o

mi n e if t h e  M at er nit y  pr o d u ct 

m a p s t o  N ati o n al  G ui d a n c e, 

  v erifi e d 

W T T f u n cti o n alit y i s  n ot i n cl u d e d i n t h e  pr o d u ct  a n d  N e w b or n  E arl y 

W ar ni n g  S c or e  
m a p t o  n ati o n al  g ui d a n c e f or  N e w  Z e al a n d.  

W S  – N e w  Z e al a n d ) f u n cti o n alit y  d o e s 

m er s  c a n  el e ct t o  u s e t hi s f u n cti o n alit y . 

 ( Pr o d u ct  Cli ni c al  S p e ci ali st –  M at er nit y  L e a d) i d e ntifi e d  N E

W T T 2  w a s 

p o st p o n e d i n t h e  n e o n at al  a p pli c ati o n  d u e t o:  

•  

W T T 2 3  i s  pl a n n e d t o  b e i ntr o d u c e d i nt o  N e o n at al  E P R  a n d  M at er nit y  o n c e t h e 

N E
f a ct or s  aff e cti n g  d e pl o y
N E
s p e cifi c ati o n t o  b e 

m e nt  h a v e  b e e n  a d dr e s s e d. It  s h o ul d  b e  n ot e d t h at 
W T T 2  w a s  n ot f ull y  a gr e e d  b y  N H S  E n gl a n d  u ntil  J u n e  2 0 2 3  a n d  a  di git al 
m a d e  a v ail a bl e  b y  N H S  E n gl a n d  b y  A ut u

m n  2 0 2 4.  

©  S y st e

m  C  H e alt h c ar e  Lt d  2 0 2 3                                                                 P a g e  8  of  1 0                                                     C O M M E R CI A L I N  C O N FI D E N C E  

 
 
 
 
 
 
 
 Investigation Findings 

3 
On the 13th of June 2022, the site was utilising the Clinical Summary application within the 
neonatal unit, the patient was not admitted to the neonatal unit and therefore was not 
recorded into the Clinical Summary application. 

In addition, the Clinical Summary application product did not contain the National Early 
Warning Score (NEWS)1, Newborn Early Warning Score (NEWS – New Zealand National 
Guidance)4, Paediatric Early Warning Score (PEWS) or the Newborn Early Warning Trigger & 
Track (NEWTT)2 functionality and therefore any recording of information on the NEWTT 
chart was not generated from the ‘Badgernet’ Clinical Summary application. 

The customer would not have been able to record National Early Warning Score (NEWS) or 
Newborn Early Warning Trigger & Track (NEWTT)2 records within the Clinical Summary 
application as this was not part of the application, and therefore had to use another system 
or forms provided directly from the NHS as advised under the Newborn Early Warning 
Trigger & Track (NEWTT) – a Framework for practice (2015)2. 

Further investigation by the trust would be required to determine what solution was used to 
generate the NEWTT chart referenced. 

The customer agreed a deployment plan of Maternity for Go Live in January 2023 and 
Neonatal EPR for the 14th of November 2023. 

The Maternity product implemented in January 2023 contains Newborn Early Warning 
Score (NEWS – New Zealand National Guidance)4 functionality requested for New Zealand 
customers that map to New Zealand national guidance. This functionality is available to 
United Kingdom customers on an elective basis and is not intended to map to Newborn 
Early Warning Trigger & Track (NEWTT)2 

System C adopt best practice and national guidance from multiple countries, customers can 
elect to use the functionality to meet their specific needs. 

Newborn Early Warning Trigger & Track (NEWTT)2 functionality is available in the Neonatal 
EPR product, which was deployed in November 2023, this does map to NHS England 
national guidelines as intended. 

NEWTT23 is planned to be introduced into Neonatal EPR and Maternity once the factors 
affecting deployment have been addressed. It should be noted that NEWTT2 was not fully 
agreed by NHS England until June 2023 and a digital specification made available by NHS 
England by Autumn 2024. 

4 
4.1 

Improvements & Lessons Learnt 

Implement NEWTT2 

(cid:120)  To plan to implement NEWTT2 in the Neonatal and Maternity application for 

delivery to the customer estate once NHS England has finalised the release of 
NEWTT2. 

(cid:120)  Ensure that the NEWS functionality is clearly distinguishable from UK national 

guidance by defining its full title of Newborn Early Warning Score. 

© System C Healthcare Ltd 2023 

                                                              Page 9 of 10                                                    COMMERCIAL IN CONFIDENCE 

 
 
 
 
 
 5 

References 

1.  National Early Warning Score (NEWS) - 

https://www.rcplondon.ac.uk/projects/outputs/national-early-warning-score-
news-2 Royal College of Physicians, July 2012.  

2.  Newborn Early Warning Trigger & Track (NEWTT) – a Framework for practice (2015) 
(https://www.bapm.org/resources/38-newborn-early-warning-trigger-track-
newtt-a-framework-for-practice-2015). British Association of Perinatal Medicine. 31st 
of May 2015. 

3.  Framework: NEWTT2 – Deterioration of the Newborn, A Framework for Practice. 
(https://www.bapm.org/resources/deterioration-of-the-newborn-newtt-2-a-
framework-for-practice). British Association of Perinatal Medicine. 19th of January 
2023. 

4.  Newborn Early Warning Score (NEWS) - 

https://www.nationalwomenshealth.adhb.govt.nz/assets/Womens-
health/Documents/Policies-and-guidelines/Newborn-Assessment-Observation-
Chart-Early-Warning-Score.pdf Te Whatu Ora, Health New Zealand. 23rd February 
2021 

© System C Healthcare Ltd 2023 

                                                              Page 10 of 10                                                   COMMERCIAL IN CONFIDENCE

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