Felix Hartley

BAPM c/o RCPCH 5-11 Theobalds Road, London, WC1X 8SH 
t: +44(0)20 7092 6085/6    e: bapm@rcpch.ac.uk 

Sent via email 
17 October 2024 

Dear Ms Andrews, 

Many thanks for contacting the British Association of Perinatal Medicine (BAPM) about the sad death of  Felix 
Hartley. We are unable to comment on the specifics of cases but we have considered the points in your letter 
raised in regards to guidance from BAPM. 

The  national  terms  and  conditions  for  NHS  consultants  in  England  are  set  by  NHS  Employers  and  we  have 
attached the latest version [Please see p18 and 40.] We have also attached A guide to Determining On-call 
Availability Supplements issued by the NHS Modernisation Agency (August 2004). There is no recommendation 
around the time required to be on site. 

BAPM is an advisory, not an executive body.  We have made some relevant recommendations that can form the 
basis for local guidance. It is the responsibility of individual trusts to implement their own processes in line with 
national guidelines.   

In our Service and Quality Standards for Provision of Neonatal Care in the UK (November 2022) [Page 24] we 
recommend; 

“For all levels of NNU [neonatal unit] it is not appropriate for a consultant to provide out of hours cover to two 
geographically separate sites simultaneously. Similarly, where a consultant or CCT holder is resident and there 
are less Tier 2 staff as a result, another consultant should provide Tier 3 cover (i.e. a single consultant cannot 
simultaneously  cover  at  Tier  2  and  Tier  3  if  such  cover  is  normally  provided  by  two  separate  clinicians  of 
appropriate training and experience).”  

In a new document from November 2023 that was NOT in place at the time of this death, Consultant Working 
Patterns – A BAPM Report [page 5] 

“Clinical  service  commitment  during  daytime  clinical  shifts  and  on  calls  is  paramount.  Any  other  service 
commitments must not prevent 24/7 immediate availability to the neonatal service including the provision of 
advice and, where required, in person attendance. In person attendance out of hours should always be within 30 
minutes.  Immediate  availability  of  consultants  will  be  dependent  on  the  experience  of  resident  Tier  2  staff, 
particularly in relation  to  airway skills.  This  may require resident consultant  models in some instances.  Local 
solutions for covering additional areas such as general paediatrics and neonatal transport will need to be robustly 
job-planned and risk assessed.”  

We recognise the importance of addressing the issues raised and suggest that we send out a safety alert to our 
members and stakeholders drawing attention to these recommendations.  

Should you require further details on any of the actions outlined or wish to discuss our response in greater detail, 
please do not hesitate to contact me directly. 

Yours sincerely, 

, BAPM President 

President: 
Treasurer: 
www.bapm.org 

Secretary: 
Chief Executive: 

Charity No:  1199712

Ms Joanne Andrews 
Area Coroner  
West Sussex, Brighton and Hove  
Record Office 
Orchard Street 
Chichester 
PO19 1DD 

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

24 October 2024  

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Felix Burton Hartley who 
died on 19 February 2023.  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  30 
August 2024  concerning the  death of  Felix Burton  Hartley  on  19 February 2023.  In 
advance of responding to the specific concerns raised in your Report, I would like to 
express  my  deep  condolences  to  Felix’s  parents  and  family  in  these  very  sad 
circumstances. NHS England are keen to assure the family and the Coroner that the 
concerns raised about Felix’s care have been listened to and reflected upon.   

Your Report raises concerns over the availability of on-call Neonatology Consultants 
over the weekend period and overnight and, specifically, the arrangements for on-call 
Consultant cover at University Hospitals Sussex NHS Foundation Trust, which covers 
two hospital sites. Relevant to NHS England’s remit, you have raised that there is no 
national  guidance  as  to  the  time  that  an  on-call  Neonatology  Consultant  should  be 
expected to attend hospital in the event of an emergency, and whether multiple sites 
can be covered by one on-call Consultant. 

All neonatal critical care units (including neonatal intensive care units) adhere to the 
national  standards  set  out  in  the  neonatal  critical  care  service  specification.  The 
service specification references the following British Association of Perinatal Medicine 
(BAPM)  standards  for  staffing  for  all  levels  of  neonatal  critical  care  units,  for  both 
neonatal intensive care units (‘NICUs’)  and Local Neonatal Units (LNUs) and Special 
Care Units (SCUs). I note that you have also addressed your Report to the BAPM. To 
assist the Coroner and family, I have summarised the main guidance on staffing from 
the relevant BAPM standards: 

•  NICUs with more than 2500 intensive care days per annum should double tier 
2 cover at night by adding a second experienced junior doctor or appropriately 
trained specialty doctor or an advanced neonatal nurse practitioner (ANNP). A 
consultant present and immediately available on NICU in addition to tier 2 staff 
would be an alternative. 

•  NICUs  undertaking  more  than  4000  intensive  care  days  per  annum  with 
onerous on call duties should consider having a consultant present in addition 
to tier 2 staff and immediately available 24 hours per day. 

                                                                                                                       
 
 
 
 
 
 
 
  
 
 
 
 • 

It is recommended that all NICUs implement consultant presence on the unit 
for at least 12 hours per day or more, as resources allow and depending on 
patient numbers and intensity. 

•  LNUs providing either more than 2000 respiratory care days or more than 750 
intensive care days annually should provide a separate Tier 3 Consultant rota 
for the neonatal unit. 

•  All LNUs should ensure that all consultants on-call for the unit also have regular 
weekday  commitments  to  the  neonatal  service.  This  is  best  delivered  by  a 
‘consultant of the week’ system, and no consultant should undertake less than 
4 ‘consultant of the week’ service weeks annually. 
In SCUs, there should be a Lead Consultant for the neonatal service. 

• 

Trusts with more than one neonatal unit should have separate cover at each level of 
all levels of staffing during office hours and out of hours.  

NHS Trusts exercise their own policies for out of hours, on call response times. This 
is linked to the Terms and Conditions for all NHS Consultants. My colleagues in the 
South  East  have  been  asked  to  engage  with  University  Hospitals  Sussex  NHS 
Foundation Trust and Sussex Health and Care Integrated Care Board  on the concerns 
raised  in  your  Report  for  assurance  purposes.  NHS  England  will  also  consider  the 
Trust’s responses to your Report carefully in due course.   

I  would  also  like  to  provide  further  assurances  on  the  national  NHS  England  work 
taking  place around  the  Reports  to  Prevent Future  Deaths.  All  reports received  are 
discussed  by  the  Regulation  28  Working  Group,  comprising  Regional  Medical 
Directors,  and  other  clinical  and  quality  colleagues  from  across  the  regions.  This 
ensures that key learnings and insights around events, such as the sad death of Felix, 
are shared across the NHS at both a national and regional level and helps us to pay 
close attention to any emerging trends that may require further review and action.   

Thank you for bringing these important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information.  

Yours sincerely,  

National Medical Director

NHS)

University Hospitals Sussex
NHS Foundation Trust

University Hospitals Sussex NHS
Foundation Trust

Trust Headquarters

Royal Sussex County Hospital
Eastern Road

Brighton

BN2 5BE

www.uhsussex.nhs.uk

Ms Joanne Andrews

HM Area Coroner

West Sussex Brighton and Hove
Parkside Chart Way

Horsham

RH12 1XH

By email only

23 October 2024

Your ref:
Our ref:

Dear Ms Andrews
Inquest into the death of Felix Burton-Hartley

Thank you for your letter of 30 August 2024, enclosing your formal report under Regulation
28 to Prevent Future Deaths, to the British Association of Perinatal Medicine, NHS England
and NHS Improvement, and the Trust.

My sincere condolences go to Baby Felix’s family.

Thank you for confirming that you did not find the timing of the attendance of the on-call
Consultant to Felix causative or contributory to his sad death. However, | understand that you
are concerned that the time in which Neonatal Consultants attend future neonatal
emergencies at the Princess Royal Hospital may vary and create a risk of future deaths.

Your Regulation 28 Report has been reviewed by the Executive team and the Women and
Children’s Division, including the Chief of Service, and the Neonatal Clinical Lead. In light of
your report, our model of care has been reviewed. A review of neonatal clinical outcomes has
also been carried out which includes our perinatal mortality rates and the incidence of hypoxic
ischaemic encephalopathy for babies born at the Princess Royal Hospital.

As you know from evidence at the inquest, our Neonatal Consultants are simultaneously on-
call for the Royal Sussex County Hospital and the Princess Royal Hospital and at these times,
they are based within 30 minutes travel time of the Royal Sussex County Hospital. These
arrangements have been in place for many years. The Princess Royal Hospital is part of
University Hospitals Sussex NHS Foundation Trust, and approximately 2200 babies are
delivered there each year. These are deliveries of 34 weeks of gestation and above, and
earlier gestations are delivered at the Royal Sussex County Hospital. The Neonatal service
has an 8 bed Special Care Baby Unit that is staffed by the Neonatal Medical team, Advanced
Neonatal Nurse Practitioners, and the Neonatal Nursing team.

The current 12 month rolling Perinatal Mortality Rate (PMR) for the Princess Royal Hospital
is 2.68/1000 births (up to and including July 2024), and this is lower than the Trust PMR of
2.78, the South-East regional benchmark rate of 4.7 (June 2023), and the Mothers and
Babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACE)
National figure of 5.0 (July 2024).

The 12-month rolling Neonatal Mortality Rate (NMR) for the Princess Royal Hospital is
0.89/1000 (up to and including July 2024), this is lower than the Trust NMR of 1.16, the South-
East regional benchmark rate of 1.4 (June 2023), and the MBRRACE National rate of 1.16.

Neonatal deaths are reviewed at a regional level and local data is benchmarked by
MBRRACE. These reviews of neonatal deaths have not highlighted the availability of the
Neonatal Consultant at the Princess Royal Hospital as a contributory factor to neonatal
deaths.

The outcomes for babies born at the Princess Royal Hospital over the last three years are in-
line in terms of safe outcomes, and are monitored regularly by the Women and Children’s
Division, and centrally by the Trust. The results are shown in the following SPC (statistical
process control) charts:

PRH Neonatal Deaths rolling 12m rate 01/21 - 08/24-Princess Royal Hospital starting 01/01/21

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The Trust is aware that the current Neonatal Consultant on-call arrangements for the Trevor
Mann Baby Unit and the Princess Royal Hospital Special Care Baby Unit do not meet the
current British Association of Perinatal Medicine standards, but our review of outcomes did
not find evidence that the current arrangements we have in place are unsafe. However, it is
acknowledged that it is right to review these arrangements. We are exploring the options for
providing a separate Neonatal Consultant on-call rota for the Princess Royal Hospital Special
Care Baby Unit, but we do not have existing Consultant resources to meet this need. The
Trevor Mann Baby Unit Consultants are already fully committed clinically, and the workforce
and financial resources are not currently available to fund the large Consultant expansion
that would be needed to provide a freestanding Princess Royal Hospital Special Care Baby
Unit rota. Therefore, in view of the complexity and interdependency of the provision of
maternity services, the Trust is approaching the Integrated Care Board (ICB) to consider
externally reviewing the current arrangements and the options for strengthening our Neonatal
Consultant on-call arrangements for the Princess Royal Hospital Neonatal service.

Yours sincerely,

Chief Executive