Evelyn March

Date: 4 November 2024      
Our Ref:  

Kevin McLoughlin 
Senior Coroner West Yorkshire (Eastern) 
His Majesty’s Coroner’s Office 
The Coroner’s Courts 
Burgage Square 
Wakefield 
WF1 2TS 

Email: 

Dear Sir  

Trust Headquarters 
St James’s University Hospital 
Beckett Street 
LEEDS  
LS9 7TF 

Chief Medical Officer 

Direct Line: 

Email: 

www.leedsth.nhs.uk 

Re: Inquest touching the death of Evelyn Grace March 

I  write  on  behalf  of  Leeds  Teaching  Hospitals  Trust  (LTHT)  in  response  to  the  Regulation  28 
report  on  this  matter,  issued  on  19  September  2024.  I  am  aware  of  the  circumstances  of 
Evelyn’s tragic death and take this opportunity to offer my sincere condolences to her family. It 
is regrettable that a Regulation 28 report was issued in the circumstances whereby LTHT was 
not an Interested Person at the inquest, and I also note that no LTHT witness was summoned to 
attend. Due to this, I have no knowledge of the evidence given on the day, beyond that held by 
LTHT  and  subsequently  the  disclosure  bundle  provided  to  us  at  our  request  to  your  office 
following the hearing. 

We  note  that  you  have  also  shared  a  copy  of  the  Regulation  28  report  with  Maternity  and 
Newborn Safety Investigations (MNSI), it is not clear to us whether you have reviewed a copy of 
their  investigation  report  into  the  death  of  baby  Evelyn  and  the  care  afforded  to  her  mother 
Rachel.  

I make my comments below against this backdrop.  

You raise four matters of concern; 

1. The Mother endured a prolonged labour and had little sleep from Sunday (24.9.23) until her 
baby was born at 04:38 hours on Tuesday (26.9.23). She was exhausted.  

2. The baby and her parents were discharged home 4 hours after the birth (08:39 hours).  

3. The death of the baby is probably due to the exhausted mother falling asleep whilst trying to 
breastfeed the unsettled baby in her own bed sometime after 01:45 hours (27.9.23). 

4.  Consideration  should  be  given  to  the  wisdom  of  discharging  a  mother  so  soon  after  a 
prolonged  labour  and  induced  delivery.  Had  she  been  permitted  to  sleep  in  hospital  for  a few 
hours knowing that her baby was being monitored, the tragedy may have been avoided. 

Chairman: 
    Chief Executive: 
The Leeds Teaching Hospitals incorporating: Chapel Allerton Hospital, Leeds Dental Institute, Leeds Children’s Hospital,  
Seacroft Hospital, St James’s University Hospital, The General Infirmary at Leeds, Wharfedale Hospital, Leeds Cancer Centre 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
 
 
 
 
 
 
 
 To  address  your  concerns,  I  have  taken  advice  from  the  senior  leadership  team  in  Maternity, 
who inform me as follows. 

Evelyn’s  death  was  reviewed  using  the  National  Perinatal  Mortality  Review Tool  (PMRT),  was 
subject  to  scrutiny  under  the  Sudden  Unexplained  Death  in  Childhood  (SUDIC)  process  and 
was investigated independently by MNSI. 

The  MNSI  investigation,  the  SUDIC  report  and  the  PMRT  into  the  death  of  Evelyn  did  not 
identify  issues  in care  which impacted  on  the  sad outcome. Additionally, MNSI  did not  identify 
any safety recommendations from their investigation.  

and father 

 both reported concerns to the Trust as part of the 
Evelyn’s mother 
mortality review process and the SUDIC process that 
 felt exhausted and that the delay 
in the induction of labour contributed to this. The Trust has subsequently updated the leaflet it 
provides  to  mothers  about  the  induction  of  labour.  This  now  includes  information  around 
bringing isotonic drinks and snacks to the ward, along with other items which may support them, 
such as eye masks, ear plugs and their own pillows. The leaflet also reiterates that the process 
of induction can take several days. 

I  respectfully  note  that  you  state  that  consideration  should  be  given  to  the  wisdom  of 
discharging a mother so soon after a prolonged labour and delivery. 

The independent MNSI investigation report documents its findings for the immediate postnatal 
care and discharge; “The Baby was born in good condition and breast fed well following birth. A 
discussion  took  place  regarding  discharge  and  the  Mother  and  Father  wished to  go  home the 
same day.  

A full newborn infant physical examination (NIPE) check was completed whilst the Baby was at 
the Mother’s side at 07:59 hours and no concerns were identified. The investigation learned that 
when mothers and babies are being discharged from the labour ward it is usual practice for the 
newborn examination to be carried out within 3 to 4 hours of the birth.  

The  parents  decided  to  return  later  for  the  hearing  screening  as  the  service  did  not  start  until 
09:00 hours and they had transport arranged to take them home at that time.  

The  staff  member  used  the  laptop  to  go  through  the  discharge  checklist.  They  covered  the 
important signs to look for, breast feeding and safe sleeping advice. The Father was packing to 
go home, and the Mother was listening intently. The Mother was noted to be very tired.  

MNSI  consider  that  the  immediate  postnatal  care  was  carried  out  within  national  guidance 
(National Institute for Health and Care Excellence (2021) Postnatal care).” 

I am also advised by the team that post-natal maternity wards are generally not environments 
conducive  to  rest  and  recuperation.  Side  rooms  are  generally  reserved  where  there  are 
infection prevention control concerns. This means that the majority of mothers are in bays with 
other  women  and  their  newborn  babies,  with  the  associated  noise  and  disturbance.  Most 
mothers will prefer the comfort of their own home.  

I  hope  that  my  response  reassures  you  that  the Trust  has  considered  the  concerns  you  have 
raised and has also undertaken detailed reviews of the care and treatment provided to Evelyn 
and her mother 

 and that the care has also be scrutinised independently by MNSI. 

Chairman: 
    Chief Executive: 
The Leeds Teaching Hospitals incorporating: Chapel Allerton Hospital, Leeds Dental Institute, Leeds Children’s Hospital,  
Seacroft Hospital, St James’s University Hospital, The General Infirmary at Leeds, Wharfedale Hospital, Leeds Cancer Centre 

 
 
 
 My thoughts remain with Evelyn’s family.  

Yours sincerely, 

Chief Medical Officer 

Chairman: Dame Linda Pollard CBE, JP, DL    Chief Executive: Professor Phil Wood 
The Leeds Teaching Hospitals incorporating: Chapel Allerton Hospital, Leeds Dental Institute, Leeds Children’s Hospital,  
Seacroft Hospital, St James’s University Hospital, The General Infirmary at Leeds, Wharfedale Hospital, Leeds Cancer Centre