Arlo Lambert

Please find below the organisational response from Sherwood Forest Hospitals NHS 
Foundation Trust to the Regulation 28 Report to Prevent Future Deaths issued by HM 
Area Coroner for Nottingham City and Nottinghamshire following the inquest into the 
death of Arlo River Phoenix Lambert. 

We reiterate our apology and condolences to Arlo’s family, and we hope this response 
and the implementation of actions reassures HM Coroner and Arlo’s family that the 
necessary changes have been implemented. 

Matters of concern raised within the report and responses for each are as follows: 

1.  The  Trust’s Antepartum  Haemorrhage  guideline  gives  no  sense  of  urgency 
when staff are faced with a bleed – here, staff failed to appreciate the potential 
for  a  sinister  cause  of  bleeding  both  at  21.18  and  later  at  03.40,  and  did  not 
appear to appreciate the fact that a volume of the bleeding may well be occult, 
by the external volume representing only a small proportion of the actual blood 
loss. Miss Al-Samarrai accepted that further work was likely to be required in 
this regard. 

The Trust acknowledges that at the time of the incident, the Antepartum Haemorrhage 
guideline did not support staff in assessing the urgency of the evolving clinical picture 
when bleeding was identified on both occasions, which delayed emergency treatment. 

Actions taken: 

The  Trust  has  reviewed  and  updated  its  Antepartum  Haemorrhage  guideline  to 
emphasise the clinical importance of bleeding in pregnancy, and the requirement for 
an immediate assessment of fetal and maternal condition with any degree of bleeding. 
The  guideline  now  informs  staff  that  best  practice  is  to  treat  bleeding  with  an 
expectation of a worse-case scenario and then de-escalate if appropriate, rather than 
treating  it  as  benign.  The  causes  of  Antepartum  Haemorrhage  section  within  the 
guideline has been amended to highlight that bleeding in pregnancy is not normal and 
can  be  unpredictable,  and  the  expectation  around  quantifying  and  documenting 
repeated episodes of bleeding within the patient record has been added to support the 
ongoing risk assessments.   

The  amended  guideline  received  a  multidisciplinary  review  including  the  obstetric 
service leads, midwifery matrons, and midwifery staff prior to ratification through the 
Maternity and Gynaecology Clinical Governance Meeting.  

Following  ratification  of  the  guideline,  the  updates  have  been  shared  with  all  staff 
members. The guideline updates have been shared via email and in person on shift 
handovers, and all staff have been asked to sign a registration sheet as evidence that 
they have read and understood the amendments. Additional support and training will 
be provided on an individualised basis to staff that do not understand the changes, 
this will be supported by their line manager and the practice development midwives.  

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 2.  Failure  to  ensure  early  reflective  accounts  were  captured  from  key  staff  in 
response to this significant event and others. I consider this to be a Trust wide 
issue.  The  Trust  cannot  begin  to  rectify  patient  safety  issues,  if  they  do  not 
understand exactly what has happened and why. This analysis can only properly 
occur with the input of those involved in care, and in circumstances where those 
individuals have had the opportunity and support of the Trust to capture early 
written accounts. The Trust currently has no clear system in place to facilitate 
this early capture of relevant accounts. 

The Trust acknowledges the importance of capturing the early recollection of events 
from staff involved in incidents / significant events and also acknowledges that at the 
time of this incident, a Trust wide process was not in place. The Trust also agree that 
the implementation of a process to capture early accounts need not conflict with any 
MNSI or Patient Safety Incident Response Framework. 

Actions taken: 

The Trust have put in place a system of capturing early Factual Recollection of Events, 
which are a description of involvement in an incident at the time it occurred but are not 
a replacement for the medical record.  

We have designed a template to capture these recollections and a guidance 
document  that provides useful information and support to staff when completing the 
template.  The  guidance  requires  staff  to  review  the  patient’s  notes  when  writing  
the  Factual  Recollection   of   Events,   ensuring   the   report   is   based   on   factual  
evidence   as  documented and reminding them that they should also describe things 
that are not in the notes that might help the investigators understand what happened 
and what can be  learned.  The  guidance  also  describes  how to  store  and  share  
completed  Factual  Recollection of Events templates ensuring that staff understand 
that they will form part of the disclosure bundle as required. 

Robust governance processes around implementation of this new system have been 
followed and include consulting with Divisional Clinical Chairs, Divisional Leadership 
teams and Clinical Governance colleagues, discussion at Patient Safety and Quality 
Committees and a pilot of the process with real time incidents. We have implemented 
an ongoing programme of engagement with staff to ensure that they understand when 
they should complete a Factual Recollection of Events template, the reason behind 
the  request  for  capturing  early  accounts,  and  how  to  access  additional  support 
available  to  assist  in  the  writing  of  the  recollection.  We  have  added  an  additional 
question into our Rapid Review and After Action Review templates, to ensure we are 
sighted to the need to consider the capture of early recollection of event at the time a 
review of the incident is conducted. 

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 Additional information: 

The Trust’s Maternity department, supported by the Professional Midwifery Advocates, 
are reviewing the immediate responses taken following an incident as defined within 
the  Trusts  Incident  Reporting  Policy  and  are  planning  to  introduce  the  Edinburgh 
Emergency Medicine ‘STOP 5’ moments for ‘Hot Debriefs’. This will enable clinicians 
involved  in  an  incident  to  have  a  5-minute  team  debrief  immediately  following  an 
incident.  During  this  team  debrief,  the  need  to  complete  a  Factual  Recollection  of 
Events will be highlighted to relevant staff and will provide the clinicians with a space 
to  discuss  what  went  well  and  the  opportunities  to  improve.  The  debrief  will  be 
documented and saved on the Incident reporting system, 

In addition to the Trust guideline changes explained above, a telephone assessment 
section  has  been  included  within  the  Antepartum  Haemorrhage  guideline.  This 
includes the need to consider transfer into hospital by ambulance and highlights the 
need  to  prepare  the  midwifery  coordinator  and  obstetric  staff  in  preparation  for  an 
incoming admission.   

Antepartum Haemorrhage cases will continue to be reviewed through our ‘triggers’  
incident  review  meeting,  to  ensure  that  the  recommendations  within  the  updated  
guideline  are  being  followed.  ‘Triggers’  is  a  weekly  multidisciplinary  case  review  
meeting where there are set criteria for cases to be reviewed and membership 
includes  Obstetricians,  Matron  for  Maternity  Governance,  specialist  midwives  
including  the  Fetal Monitoring Lead, Audit Lead and Clinical Governance Midwives, 
incidents are  then escalated in line with the Incident Reporting Policy. The Triggers 
meeting is an  open forum for staff members to attend for their own learning, and 
aims to identify  learning  from  incidents,  along  with  identification  of  cases  further  
escalation  and  investigation. Cases will also be escalated into regional and national 
conversations as  appropriate. 

The Maternity team are currently developing an Antepartum Haemorrhage scenario 
video that includes role play of a phone call in progress whilst a midwife completes the 
Birmingham  Symptom  Specific  Obstetric  Triage  System (BSOTS) 
telephone 
proforma. This consists of a prompt and brief assessment (triage) of women when they 
present  with  unexpected  problems  or  concerns,  and  then  a  standardised  way  of 
determining the clinical urgency in which they need to be seen. This will be available 
for staff members to access anytime and has been included within our BSOTS Training 
Needs Analysis (TNA). 

August 2024 

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