Zachary Taylor-Smith

9 May 2024 

PRIVATE & CONFIDENTIAL 
Mrs Susan Evans   
HM Area Coroner for Derby and Derbyshire  
St Katherine's House  
St Mary's Warf  
Mansfield Road  
Derby, DE1 3TQ 

Dear Madam 

Zachary Taylor-Smith: Regulation 28 Report Response 

I am writing in response to the Regulation 28 Report dated 14 March 2024, following the Inquest into 
Zachary Taylor-Smith's sad death.  

Conscious that Zachary's family will receive a copy of this response, I firstly want to begin by offering 
my deepest condolences to his parents and family.  I am sorry the care we delivered to Zachary and 
his parents was not as it should have been. 

We are determined to ensure the care our families receive is of the highest quality and our staff can 
deliver good quality care at all times.  As such, our Women and Children's Division staff have collated 
the specific responses Zachary's case, but I also write to provide further assurance on the actions we 
continue to take, including through our wider Maternity & Neonatal Improvement Programme.  

As a Trust we welcome working closely with our families, and having benefitted from Zachary's parents' 
continued engagement, I also wish to acknowledge and give thanks for their ongoing work with us over 
what are incredibly difficult events.  

Scope 

With our commitments to improve, the investments we have made, and the scale of the Maternity & 
Neonatal  Improvement  Programme,  we  note the  matters  of  concern from the Regulation  28 Report, 
namely:-: 

1.  Staff lacking appreciation and proper understanding of the significance of the 4-hour period after 
birth in relation to indicators of a deteriorating baby and the potential over emphasis placed on the 
possible innocuous explanation for grunting in that period. 

2.  Staff lacking appreciation of the significance of the timing between rupture of membranes in a pre-
term  birth  and  birth  and, therefore, failing  to  note  or  ask  to  be  furnished  with that  information to 
inform their assessment of the risks of infection in babies.  

3.  The persisting cultural issues affecting the relationships and communication between maternity and 

neonatal staff.  

4.  Absence of an effective system in place to ensure required reviews remain live until completed.  
5.  Absence of a formal mechanism for reviewing whether it is safe for planned inductions to take place 

in the context of ward and neonatal units levels of activity and capacity. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Trust Response 

Please find enclosed commentary that has been prepared to give assurance on the actions taken to 
address the points of concern you have raised and following the Regulation 28 Report. 

Appendix  1  (attached)  is  the  action  plan  which  documents  the  actions  already  taken  and  those  in 
progress.  These include actions generated because of our internal investigations into Zachary's death, 
and additional actions because of your findings following Zachary's Inquest.  This action plan creates a 
single  location  whereby  actions  can  be  monitored,  and  evidence  of  completion  embedded,  with 
continual review to maintain assurance into the longer term.  

The Trust has over the last 2 years committed significant time and resource into improving the safety 
of care delivery in our maternity services.  Internal and external reviews and reports have helped us 
identify our areas for focus.  The extensive Maternity & Neonatal Improvement Programme in progress 
includes  investment  in  additional  staff,  improved  equipment  and  facilities,  as  well  as  embedding 
improvements  to  system  and  process.  We  have  also  strengthened  the  leadership  roles  we  have  to 
include  the  recently  newly  appointed  Director  of  Midwifery,  Divisional  Director  of  Operations,  and 
Divisional Medical Director with a Divisional Director of Nursing who has been in post for just over a 
year.    We  acknowledge  that  whilst  we  have  already  delivered  on  positive  change,  we  are  not 
complacent  and  are  committed  to  acting  openly  and  honestly,  examining  all  the  facts  and  with  the 
determination to deliver improvements for future care. As such, in addition to individual incident reviews, 
we have proactively requested and welcomed reviews into our services, which are informing our work 
and  delivering  demonstrable  improvements.  We  have  also  appointed  46  additional  midwives  and 
increased our medical establishment across obstetrics and anaesthetics. 

The Maternity & Neonatal Improvement Programme contains 14 broad workstreams. Each workstream 
has its own clinical lead, project lead and operational lead that drive forward actions with set milestones, 
which  are  then  monitored  by  the  Board.  Our  patient  experience  manager  also  provides  feedback 
received from our patient population into each workstream alongside input from our Maternity Voices 
and Neonatal Partnership Group.  

The Trust is also working closely with NHS England and we are the only Trust that have proactively 
asked  to  enter  the  National  Maternity  Safety  Support  Programme.    This  provides  the  Trust  with 
additional  senior  expertise/consultants  through  two  Maternity  Improvement  Advisors:  a  very  senior 
midwife/Director of Midwifery equivalent and an Obstetric Consultant. Their role is to give independent 
advice, verification/and or escalation of risks alongside the Trust to the Regional Chief Midwife, the ICB 
and the CQC which monitor progress of the Maternity & Neonatal Improvement Programme through 
the Regional Oversight Meeting. 

I  hope  that  this  response  demonstrates  that  the  Trust  is  committed  to  making  changes  following 
Zachary's tragic death and to improving care for our future patients. 

Yours sincerely 

Executive Chief Nurse 
University Hospitals of Derby and Burton 

 
 
 
 
 
 
 
 
 
 Response to concerns identified in the Regulation 28 Report to Prevent Future Deaths issued 
on 14 March 2023 

1.  Staff  lacking  appreciation  and proper  understanding of  the  significance  of  the  4 hour 
period after birth in relation to indicators of a deteriorating baby and the potential over 
emphasis placed on the possible innocuous explanation for grunting in that period. 

Actions completed: 

• 

Implementation of the Newborn Track and Trigger 2 (NEWTT2) framework Immediate Care 
and Observations of the Newborn – Maternity / Neonatal. 

The NHSE Three Year Delivery Plan for Neonatal and Maternity stipulates roll out of NEWTT2 by 2025. 
Following this case, roll out of NEWTT2 was fast-tracked across UHDB and implemented on 5.9.23. 
NEWTT2  is  specifically  designed  for  the  postnatal  setting  and  immediate  period  following  birth.  It 
identifies  at  risk  babies  and  provides  an  updated  Newborn  Early  Warning  chart  aligning  to  current 
national  recommendations  for  newborn  care. The  tool  develops  a  more  rigorous  set  of  criteria  than 
timing  alone  and  the  chart  includes,  for  example,  recording  of  parental  concern  to  acknowledge  the 
importance of the views of the family in addition to the wider multi-disciplinary team.   

NEWTT2  also  provides  an  escalation  tool  and  a  standard  response  and  review  tool  for  the 
multidisciplinary  team to  promote  consistency  between  healthcare  professionals  and  ensure that  the 
team and family are involved in and fully  informed of the actions required for a baby to receive safe 
care. The response tool facilitates the documentation of the response taken and subsequent actions 
required.  In addition, use of this tool decreases the risks of professional disagreement and other team 
factors from impacting negatively on patient care - the institution of checklists/frameworks/tools which 
clearly describe not only assessment criteria and thresholds for concern, but also the pathway of care, 
escalation  and  intervention  that  is  required  as  a  result,  reduces  the  likelihood  of  negative  impact  of 
normal human factors.  Embedding the inclusion of the family in NEWTT2 further enhances the safety 
of the care at the bedside and its use and efficacy forms part of our ongoing audit programme.  

Immediate learning from this case was cascaded via a learning vignette to all staff on 21.12.22 and has 
been included into mandatory training for the clinical MDT. Additional learning and sharing of the reports 
with clinicians involved in the case was completed. 

Following learning from the Inquest a further amendment to NEWTT2 has been completed (see exert 
from  guidelines  below)  and  was  implemented  week  commencing  15.04.24.  This  is  to  ensure 
consistency of escalation in babies with signs of respiratory distress and further support the recognition 
of babies at risk.  Our amendment to guidance states: 

'Babies may have some mild respiratory distress in the first 4 hours after birth. This can be 
due  to  normal  physiological  transition  from  in  utero  respiration  through  the  placenta  to 
breathing in air. Babies can have mild increase in respiratory rate, and occasional intermittent 
grunting in this period. 

'However, if the baby has features of respiratory distress and the NEWTT2 score indicates 
escalation to neonatal team, a review should be undertaken, and the baby reviewed as per 
the  NEWTT2  guidance.  Babies  with  such  mild  respiratory  distress  may  not  need  to  be 
screened for infections immediately if they are otherwise well but should be kept under close 
observation using the NEWTT2 charts. If the respiratory distress worsens or there are other 
risk factors or clinical indicators for early neonatal infection, tests for infection and antibiotics 
should be considered as per the Early Onset Neonatal Infections guidelines.'  

The tool is explicit in what action should be taken and within what timeframe based on the baby's clinical 
presentation and any concern raised by the parents. Communication of these changes to the guideline 

 
 
 
 were made to both the maternity and neonatal teams via multiple communication channels including 
message groups, staff email, verbal update at staff handovers, and in team huddles through week of 
15.04.24. This is normal process for changes to guidance. 

Actions in progress: 

•  BadgerNet & Padlet app introduction 

Learning from incidents is already cascaded through a variety of formats including daily safety huddles 
and email bulletins. Implementation of BadgerNet (described in more detail below) represents a whole 
system  change  and  is  central  to  driving  forward  best  practice  in  care  planning,  clinical  care,  patient 
access to information and audit. It is important to embed this properly within the teams but following this 
we  also  intend  to  explore  the  introduction  of  the  Padlet  App  as  a  tool  for  shared  learning,  guideline 
updates, safety alerts and practice reminders for all staff to have access across Maternity and Neonatal 
services. Padlet is a secure visual communication board for content to be disseminated safely and so 
can  be  accessed  inside  and  outside  of  the  workplace.  This  would provide  an  additional  medium  for 
communicating with clinical teams.  

2.  Staff  lacking  appreciation  of  the  significance  of  the  timing  between  rupture  of 
membranes  in  a  pre-term  birth  and  birth  and  therefore  failing  to  note  or  ask  to  be 
furnished with that information to inform  their  assessment  of  the  risks  of  infection in 
babies.  

Actions completed: 

•  Guidelines review 

Following this case, the guidelines for the management of Group B streptococcus, Induction of Labour, 
Labour Care and Pre-term Labour care were reviewed and updated on 14.3.23. This is to ensure clear 
and  consistent  guidance  is  available  to  all  staff  to  support  identification  of  babies  at  risk  of  infection 
related to time of rupture of membranes and time of delivery in both preterm and term babies and the 
ongoing care/management required.  

As above, NEWTT2 was implemented on 05.09.23 to take into account as a risk factor the identification 
of babies born preterm with interval between rupture of membranes and time of birth over 18 hours, 
and these babies automatically trigger for enhanced observations under the NEWTT2 framework.  

•  Communication 

Communication  within  a  busy  clinical  setting  can  be  challenging  and  to  facilitate  best  transfer  of 
information we are adopting multiple new ways of communicating with staff to ensure key messages can 
be communicated promptly and efficiently. 

o 

'Spotlight on maternity' is a new monthly communication to all staff, which commenced in April 
2024.  There  will  be  a  different  theme  and  focus  each  month.  April  was  focused  on  risk 
assessment, used to highlight the requirement for robust risk assessment of babies at risk of 
infection including the significance of timing between rupture of membranes and birth. May is 
focused on fetal monitoring. A 6-month programme has been agreed by the Division to reflect 
themes from clinical incidents. 

o  A 'daily safety brief' is used to communicate verbally at all handovers any contemporaneous 
safety/learning  points  in  maternity  and  neonatology.  This  allows  timely  and  prompt 
communication of important safety and learning issues with all clinical staff.  

o  We  have  improved  and  diversified  the  membership  of  our  closed  staff  maternity  group, 
extending to both obstetric, anaesthetic and neonatal teams to provide an alternative way to 
communicate  with  staff.  This  provides  an  additional  forum  for  discussion  and  engagement 

 
 
 
 
 
 
 
 
 
 
 
 
 surrounding  systems  improvements  with  colleagues  outside  the  Women  and  Children's 
Division,  such  as  theatre  staff  and  anaesthetic  colleagues  -  audit  of  compliance  for  the 
administration of prophylactic intravenous antibiotics for pre-term vaginal births to be completed 
for all eligible cases giving birth in Quarter 1 24/25. 

Actions in progress: 

•  BadgerNet 

BadgerNet  electronic  patient  record  (EPR)  launch  is  scheduled  for  18.06.24.  This  will  ensure  the 
accurate and visible calculation of time between rupture of membranes and time of birth in both preterm 
and term deliveries reducing possibility of human error and flagging babies that are at risk. The system 
will support audit of completion of risk assessments and will form part of our extensive ongoing audit 
programme.  

•  Parental experience 

Baby Zachary's parents, Hannah and Tim, have kindly agreed to support learning by taking part in a 
case  study  that  can  be  shared  will  all  staff  and  inform  future  education  and  learning,  including  the 
recording  of  a  video. This  case  study  will  encompass all  recommendations  and  learning  identified  in 
both local investigation and the inquest. We are incredibly grateful for the continued time and support 
that Hannah and Tim are investing in working with us.  

•  Audit 

In response to work around the use of prophylactic antibiotics being administered for pre-term vaginal 
births we have developed an audit which will also form part of our ongoing audit programme for quarter 
1 compliance 24/25 to ensure learning and actions have been embedded. 

To measure improvement we will also be carrying out audits of maternity records. We will perform: 

o  Spot checks of records to audit completion of a holistic risk assessment.  
o  An audit over 12 weeks using a rapid safety proforma to ensure correct identification of preterm 
babies whose membranes ruptured over 18 hours to time of delivery. The proforma will audit 
time of rupture of membranes to time of delivery and measure compliance with identification of 
prolonged  rupture  of  membranes  (PROM)  by  risk  assessment  and  also  compliance  with 
administration of antibiotics in preterm labour.  

3.  The persisting cultural issues affecting the relationships and communication between 

maternity and neonatal staff.  

We  acknowledge  cultural  issues  and  the  need  to  address  this.  The  implementation  of  checklists, 
guidelines  and  frameworks  reduces  the  potential  for  a  negative  impact  of  human  factors  on  care 
delivery, and we have prioritised completion of these actions in our improvement work as a result. Staff 
work hard, together, to deliver high quality care - having the right number of staff, with clear guidance 
and training, reduces stress and improves communication.  Care for our staff through wellbeing support, 
access to training and education, peer support, appraisal, and visibility of leadership also impact - and 
we  have  prioritised  all  of  these.  We  believe  that  when  people  feel  psychologically  safe  within  their 
working  environment,  we  create  the  best  possible  culture  that  promotes  respect  and,  importantly, 
service development and improvement. 

Actions completed: 

 
 
 
 
  
  
 
 
 
 
 •  Culture and civility 

Culture and Civility within maternity and neonatal services is a Priority 1 project for the Trust Maternity 
& Neonatal Improvement Programme. The project, which commenced in August 2023, has a focus on 
improving staff behaviours across all staff and services that routinely provide maternity and neonatal 
care. This project is using information and recommendations from both national and local reports and 
surveys relating to culture within maternity and neonatal services, and has developed an action plan to 
deliver improvements that are identified to have an impact on culture and civility. Actions are tracked 
within  the  project  group  and  the  governance  structure  within  which  the  Maternity  &  Neonatal 
Improvement  Programme  sits.   There  is  wide  project  group  membership  including  clinical  and  non-
clinical staff who deliver maternity and neonatal services, and Trust experts in this field. 

The Culture & Civility Work Programme hosted two Culture and Civility workshops with places offered 
to clinical staff in March 2024. The outputs from these workshops included 'what good culture looks like 
to me' and a good culture and civility charter.  These are in the process of being published and socialised 
to the teams.   

The  Trust  provides  mandatory  training  using  the  Practical  Obstetric  Multiprofessional  Training 
(PROMPT)  package  across  our  service.  This  model  provides  evidence-based  training  for  maternity 
units with midwives, obstetricians and anaesthetists all attending study days together. The training is 
proven to have a significant positive effect on both maternal and neonatal outcomes as well as improve 
teamworking  across  the  multiprofessional  groups.  Attendance  is  mandated  annually,  and  Trust 
compliance is currently 85.81% (March 2024). 

Actions in progress: 

• 

Improving performance in practice 

An Improving Performance in Practice (IPIP) Diagnostic culture survey was completed July 2023. IPIP 
are a team of experts with over 20 years' experience in organisational culture. They work in partnership 
with Denison Europe which supports organisations to develop high performing cultures. Both maternity 
and  neonatal  staff  have  completed  the  culture  survey  to  provide  a  baseline  reading  of  the  service's 
culture and is being used to inform the organisational improvement taking place. The Trust team have 
met with IPIP and the proposed actions from them will be built into our wider improvement plans.  

•  Staff engagement 

The NMC and GMC are hosting a joint cultural workshop at our request for divisional staff in May 2024, 
and with two further dates later in the year.  

The staff members involved in the inquest will be invited to join the maternity and neonatal culture and 
civility  project  group,  to  support  in  ensuring  that  they  can  share  their  valuable  experience,  and  that 
clinical staff voices are both heard and can actively contribute to improving the culture within maternity 
and neonatal services at the Trust. It is vital to listen to our staff group and use their experiences to 
drive improvements in the service. 

•  Safety huddles  

It is recognised that safety huddles and multidisciplinary team (MDT) discussions did not consistently 
include neonatal services.  

o  The  maternity  service  has  already  adopted  the  Royal  College  of  Obstetricians  and 
gynaecologists  (RCOG)  Team  of  the  Shift  huddle.    This  huddle  promotes  excellence  in 
teamwork, supports optimal communication, an understanding of team members' job roles 

 
 
 
 
 
 
 
 
 
 
 
 
 
 and encourages a shared mental model of the entire team’s workload.  Team of the Shift 
is now to be expanded to the entire MDT including Neonatal team members. 

o  Daily safety huddles are carried out at 08:15 with the operational matron, flow co-ordinator 
and operational ward managers.  Staffing and elective work is discussed, the OPEL sitrep 
is  completed,  and  any  potential  issues  raised. A  second  huddle  takes  place  at  15:30  to 
review workload and staffing into the afternoon/evening. 

o  A virtual cross-site safety briefing huddle takes place at 11:00 each day.  It is mandatory 
for  all  professional  groups  to  attend  (MDT  including  neonatology,  obstetrics,  and 
anaesthetics).    Workload  across  the  maternity  service  is  reviewed  -  Information  and 
discussions are documented on a huddle proforma.  A tracker is monitored and any non-
attendance from a professional group challenged in real time, escalating to the operational 
Matron.   Attendance  is  further  reported  and   monitored  the      Business  Unit  governance 
meeting. 

•  Junior doctor induction 

Junior  doctors  join  the  team  every  six  months  as  a  normal  rotational  cycle,  creating  a  continuously 
evolving workforce. Given that the closest working relationships at the bedside are between rotational 
junior doctors and midwives, this is a relationship that needs particular attention to ensure rapid ability 
to work together effectively, with shared understanding of roles and responsibilities and understanding 
of how to work closely within newly formed teams. We have implemented a session in the junior doctor 
induction  and  training  programme  led  by  midwives to foster  understanding  of  each  other's  roles  and 
supportive ways of working. 

4.  Absence  of  an  effective  system  in  place  to  ensure  required  reviews  remain  live  until 

completed  

Actions completed: 

•  Changes pending BadgerNet introduction 

Until  BadgerNet  EPR  is  implemented  in  June  2024,  we  have  introduced  a  telephone  consultation 
document to record all telephone consultations/discussions/requests for review between maternity and 
neonatal staff.  This record includes date/time, patient details, problem discussed, advice given and the 
outcome. These records  are  reviewed  at  each  handover  (morning  and  night  shift). This  document  is 
completed by the neonatal team member who receives any calls from babies in postnatal settings and 
any pending reviews will be handed over to the oncoming team.  Communication from staff member to 
staff member is done using SBAR and AID format; both tools to support effective communication. 

The  Advice,  Inform,  Do  (AID)  communication  tool  is  a  national  tool  produced  by  Each  Baby 
Counts/RCOG.    The  tool  is  utilised  when  escalating  concerns  in  clinical  practice  to  ensure  clear, 
succinct communication  with  the  right  person  at the right  time. The  tool  is  now  included  in  maternity 
MDT mandatory training and practiced during simulated sessions to increase clinician confidence, and 
facilitate embedding into routine practice.  

Actions in progress: 

•  Whiteboard 

Neonatal reviews that are requested by the midwifery team will be recorded on a live whiteboard in the 
clinical  areas  so  that  outstanding  reviews  are  visible  to  the  whole  team.  Once  the  review  has  been 
completed  this  will  be  amended  to  state  the  review  has  taken  place,  including  time  and  date.  The 
whiteboards  are  utilised  at  all  ward  handovers  and  will  flag/alert  outstanding  reviews  that  are  still 
required. On the postnatal ward the whiteboard is in place electronically. All areas will have whiteboards 
by the end of June 2024. 

 
 
 
 
 
 
 
 
 
 Following  the  BadgerNet  launch  on  18.06.24,  all  requested  reviews  by  midwifery  staff  will  also  be 
recorded using the SBAR escalation tool in the BadgerNet EPR system, and changes to management 
will also be recorded in the EPR.  

5.  Absence of a formal mechanism for reviewing whether it is safe for planned inductions 
to take place in the context of ward and neonatal units levels of activity and capacity 

Actions completed: 

•  Birthrate Plus / activity reviews 

Midwifery  Services  regularly  undertake  workforce  review  using Birth  Rate  Plus. This  is  an approved 
workforce methodology to ensure the right number of midwives to meet activity and acuity.  Whilst the 
Trust  is  currently  staffed  above the  latest  2021  recommendations,  a  review  is  underway  with results 
expected in the summer. 

A daily review of activity, staffing, acuity and planned elective activity including inductions of labour takes 
place at the cross site daily safety huddles. This is routinely attended by senior midwives, matron, the 
obstetrician on call and the neonatal team to provide senior operational oversite of activity and capacity.  

Band  7  Flow  maternity  coordinators  commenced  March  2024,  providing  daily  prioritisation,  flow 
optimisation and coordination of all acute and planned activity. 

Daily  Sitreps  are  reported  both  internally  and  to  the  Midlands  region  by  UHDB  and  all  other  East 
Midlands Units to ensure shared understanding of demand/capacity and any need for escalation and 
mutual aid requests through the Local Maternity and Neonatal system (LMNS) and the ICBs.   

The internal escalation policy for both maternity and neonatal services has been reviewed and updated 
to ensure clear process of management of escalation, including delay of induction of labour if capacity 
is significantly reduced.  This policy is reviewed regularly. 

Actions in progress: 

There is an ICB led regional escalation policy to inform system-wide decision-making around closing to 
admission/diverting to other units across the system. It is in place with evaluation ongoing.    

Formalisation of Neonatal Sitrep within the Maternity Escalation policy is in progress.   In addition senior 
Neonatal Clinical (medical and nursing) and Operational team members are involved in the planning of 
elective and non-elective activity, and this will be embedded into the current MDT planning process. 

We hope this response provides you with a clear explanation of the actions taken to date and further 
actions  planned  or  underway,  not  only  in  response to your  findings,  but  also  our  wider  improvement 
plans.  

We believe that significant progress has already been made, but are deeply committed to continuing 
work that is required. 

May  we  conclude  by  reiterating  our  sincere  condolences  to  Zachary's  parents.  We  are  immensely 
grateful for their strength in their ongoing partnership with us in our improvement work.