Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0067, written 6 Feb 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Feb 2024 |
|---|---|
| Reference | 2024-0067 |
| Deceased | O’Shea Dover |
| Coroner | Peter Straker |
| Coroner area | London (North) |
| Category | Child Death (from 2015) · Emergency services related deaths (2019 onwards) |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Her Majesty’s Coroner for the Northern District of Greater London (Harrow, Brent, Barnet, Haringey and Enfield) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. AACE Association Ambulance Chief Executives. 2. Department of Health and Social Care, 33 Victoria Street, London SW1H 0EU 1 CORONER I am Peter Straker, Assistant Coroner, for the coroner area of Northern District of Greater London 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. Her Majesty’s Coroner for the Northern District of Greater London (Harrow, Brent, Barnet, Haringey and Enfield) 3 INVESTIGATION and INQUEST On the 27th May 2022 I opened an investigation touching the death of O’Shea Medad Dover who was 1 month old when he died. I opened an inquest on the 26th of September 2022, the inquest concluded on the 1st of February 2023. The conclusion of the inquest was the following narrative. was 30 weeks pregnant when she experienced abdominal pain and called emergency services. The call was wrongly categorised so paramedics arrived 44 minutes later than should have been the case. Midwifery advice was for the paramedics to bring obstetric and neonatal support. They did not follow this advice for three reasons… to hospital because pre-term deliveries require full 1. They thought was soon to deliver - a conclusion they’d be less likely to have reached had the call been correctly categorised and they’d been with her 44 minutes earlier; 2. Extrication from the property was challenging. 3. LAS guidance told them not to extricate if delivery is thought to be imminent. Recognising the seriousness of the situation two midwifes came to . They deemed her presentation to be more in keeping with placental abruption than imminent delivery and assisted paramedics in extrication hospital at 22.30. At 22.44, there was no foetal heart rate. At 23.04 O’Shea was delivered, resuscitation was started and caused a return of spontaneous circulation at 23.12. Given these things, it is likely O’Shea was subjected to acute severe hypoxia between 22.14 and 22.19. If the call to emergency services had been correctly categorised, CTG monitoring to recognise foetal distress prior to the hypoxia at 22.14 which would have prompted emergency caesarian. Had this happened it’s likely O’Shea would have survived. would have probably been in hospital by 20.57, Hme enough for and taking her to 4 CIRCUMSTANCES OF THE DEATH As set out in the above narrative. Since O’Shea’s death London Ambulance Service has added “JRCALC Plus” guidance stating where delivery is not progressing the patient should be conveyed to a hospital with obstetric support. 5 CORONER’S CONCERNS The MATTERS OF CONCERN are as follows. – 1. Consideration to be given for the national JRCALC guidance to include the London Ambulance Service’s JRCALC Plus recommendation that where delivery is not progressing the patient should be conveyed to an obstetrics unit; 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation has the power to take such action. Her Majesty’s Coroner for the Northern District of Greater London (Harrow, Brent, Barnet, Haringey and Enfield) 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by Thursday the Twenty-Fifth of April 2024 I, the assistant 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;- The Family 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 6-2-2024
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.
29 April 2024 Association of Ambulance Chief Executives 25 Farringdon Street London EC4A 4AB Mr Peter Straker HM Assistant Coroner for Northern District of Greater London Dear Mr Straker O’SHEA MEDAD DOVER (DECEASED) I am writing in response to the preventing future deaths report that was sent to Support Manager for Association of Ambulance Chief Executives and I respond as our Director of Operational Development and Quality Improvement on behalf of AACE. , Clinical Firstly, on behalf of AACE, I would like to extend our sincere condolences to the family of O’Shea Dover. It may be helpful for us to explain that AACE is a private company owned by the English and Welsh NHS ambulance services. Its purpose is to support its members, UK NHS ambulance services, in the implementation of national agreed policy and to act as an interface, where appropriate at a national level, between them and their stakeholders. It is a company owned by NHS organisations and possesses the intellectual property rights of the Joint Royal Colleges Ambulance Liaison Committee UK ambulance service clinical practice guidelines (the “JRCALC guidelines”). AACE is not constituted to mandate or instruct ambulance services however it has national influence via the regular meetings of ambulance chief executives and chairs along with a network of national specialist sub-groups. It is important to note that the JRCALC guidelines are advisory and have been developed to assist healthcare professionals inform patients and to make decisions about the management of the patient’s health, including treatments. This advice is intended to support the decision making process and is not a substitute for sound clinical judgement. The guidelines cannot always contain all the information necessary for determining appropriate care and cannot address all individual situations; therefore, individuals using these guidelines must personally ensure they have the appropriate knowledge and skills to enable suitable interpretation. We respond in relation to your matter of concern: Consideration to be given for the national JRCALC guidance to include the London Ambulance Service’s JRCALC Plus recommendation that where delivery is not progressing the patient should be conveyed to an obstetric unit. We have liaised with our lead maternity and consultant paramedic colleagues at London Ambulance Service to understand more about the decisions made by the attending ambulance clinicians and midwives that attended the address, and around whether to move the patient to hospital immediately or not. We have also taken time to understand the learning and changes that have been made in London in relation to this case. We are consulting with our expert advisors for our JRCALC guidance, obstetricians and midwives and the NHS England National Maternity team. All our JRCALC guidance is updated on a frequent basis. The guidance is available to all UK ambulance paramedics and is used on an App. We regularly respond to learning from incidents and issues or concerns raised so that we can continue to improve the guidance towards improving patient care. We currently have JRCALC guidance for a range of maternal emergencies, and we have guidance called ‘Maternal care (including obstetric emergencies overview)’ and ‘Birth Imminent -normal birth and birth complications’. These guidelines detail the appropriate destination for conveyance, including whether the patient should be conveyed to an obstetric unit, birth/birthing centres (or 'standalone' maternity units) or in some cases to the emergency department. As a result of the learning from this incident two guidelines are now under review and will take into account the matters of concern you have raised about conveying the patient if delivery is not progressing. The decision whether to move the patient may differ in every individual situation and would continue to be made by the attending clinicians. The guidance will be updated following the review we have commenced, and this is expected to take around three months. When the guidance is updated it will be issued as a clinical update onto the App following our usual process which involves approvals from JRCALC and our National Ambulance Medical Directors group (NASMeD). If you have any further questions please do not hesitate to get in touch. Yours sincerely Director of Operational Development and Quality Improvement AACE
From Minister of State for Care 39 Victoria Street London SW1H 0EU 24 April 2024 Our Ref: Mr Peter Straker North London Coroners Court 29 Wood Street Barnet EN5 4BE Dear Mr Straker, Thank you for your report of 6 February 2024 to the Secretary of State for Health and Social Care about the death of O’Shea Dover. I am replying as Minister with responsibility for urgent and emergency care. Please accept my sincere apologies for the delay in responding to this matter. I would like to assure you that the department is mindful of the statutory responsibilities in relation to prevention of future deaths reports and we are prioritising responses as a matter of urgency. Firstly, I would like to say how deeply saddened I was to read of the circumstances of O’Shea’s death and I offer my sincere condolences to their family. I am grateful to you for bringing these matters to my attention. The report raises concerns about ambulance service response and the guidance provided on conveying patients to hospital where a pre-term delivery is not progressing. You asked for consideration to be given to the national Joint Royal Colleges Ambulance Liaison Committee (JRCALC) guidance that where a delivery is not progressing, patients should be conveyed to an obstetrics unit, which is the approach the London Ambulance Service has taken in their ‘JRCALC Plus’ guidance. My officials have raised these concerns with NHS England (NHSE) as the body responsible for the oversight of the operational delivery of ambulance services nationally. NHS England have responded to confirm that they are working with the Association of Ambulance Chief Executives (AACE) to support their review of the concerns you have raised. I understand that AACE will be responding to you shortly on the action being taken. Thank you once again for bringing these concerns to my attention. Yours, 1
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