Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0233, written 19 May 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 May 2025 |
|---|---|
| Reference | 2025-0233 |
| Deceased | Emmy Russo |
| Coroner | Thea Wilson |
| Coroner area | Essex |
| Category | Child Death (from 2015) · Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | The Princess Alexandra Hospital NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: The Chief Executive, Princess Alexandra Hospital NHS Foundation Trust 1 CORONER I am Thea Wilson, assistant coroner for the coroner area of Essex 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. 3 INVESTIGATION and INQUEST On the 9th July 2024 I commenced an investigation into the death of Emmy Russo, aged 3 days. The investigation concluded at the end of the inquest on the 7th May 2025, having been heard on 24th, 25th and the 26th March and the 6th and 7th May 2025. Emmy Russo was delivered by category 1 caesarean section at Princess Alexandra Hospital at 21:30 on the 9th January 2024. Emmy’s mother had arrived at the hospital in labour earlier that day, having been booked in for an induction at 41+4 weeks. Her evidence was that she had refused earlier induction having not been provided with full information on the risks of proceeding with pregnancy and having been encouraged by the midwives to labour naturally. At 13:45 Emmy’s mother’s membranes ruptured. Meconium was suspected but no speculum examination was done to confirm. At 15:10 meconium was confirmed. Emmy’s mother was started on a CTG trace and transferred to the labour ward, but no doctor’s review took place although the witnesses agreed that one was indicated at this time. The CTG which started at 15:36 was never normal, with indications of hypoxia throughout (showing a lack of cycling and no accelerations throughout, and a shallow deceleration at 16:31). No full holistic review with a doctor took place although Emmy’s mother’s midwife believed she had requested one shortly after 17:10. Prolonged decelerations occurred at 18:12, 19:47 and from 20:55 onwards. Doctors’ reviews occurred at 18:30 and 18:55, but confirmed that labour should proceed. Reviews by a doctor were indicated at 19:30 and at 19:47, but no review was requested (although there was a senior midwife review following the 19:47 deceleration). A doctor’s review was requested at around 21:00 and a decision to proceed to category 1 caesarean section was made at 21:13. Emmy Russo was born in a very poor condition at 21:30. There were a number of missed opportunities to have delivered Emmy sooner, particularly at the review at 18:30. The evidence was that had a decision been made to deliver her at or before 19:30, her death would probably have been avoidable and had a decision been made to deliver her between 19:30 and 20:55, it is possible that her death would have been Regulation 28 – After Inquest Document Template Updated 30/07/2021 avoidable. The conclusion of the inquest was a narrative as follows: The deceased died as a result of an acute hypoxic brain injury sustained shortly before birth. The medical cause of death was given as: 1(a) Severe Hypoxic Ischaemic Encephalopathy 1(b) Placental Dysfunction 4 CIRCUMSTANCES OF THE DEATH Post-dates baby born at Princess Alexandra Hospital following a hypoxic injury in the period shortly prior to birth, leading to severe hypoxic ischaemic encephalopathy. Emmy was born in a very poor condition. She was resuscitated and transferred to Addenbrookes’ Hospital for ongoing intensive care on 10th January, at less than 12 hours of life. At Addenbrookes’, treatment was carried out to support Emmy’s organs, including treatment for meconium aspiration syndrome. Her organs recovered quickly, however scans indicated a severe hypoxic ischaemic brain injury. Emmy’s care was reoriented towards palliative care and she was extubated at 21:55 on the 12th January 2024. Her death was confirmed within an hour. 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) (1) The evidence of the current information given to patients at 40 weeks’ pregnant on the decision over whether to accept the offer of an induction from 41 weeks does not reflect NICE guidance on the information needed by patients to make an informed choice on induction. Whilst it provides details of the risks associated with induction, it does not provide information on the risks of continuing with pregnancy beyond 41 weeks. (2) The evidence given at inquest indicated a lack of understanding and/or consistency over when concerns about labouring mothers and/or the CTG trace should be escalated for doctor review. Evidence was given on the measures put in place to address issues with escalation, including “Teach or Treat” and “AID” tools, however, there was limited evidence that these are understood by the working midwives and/or advertised to them by way of regular reminders. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by July 14th 2025. I, the coroner, may extend the period. Regulation 28 – After Inquest Document Template Updated 30/07/2021 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. COPIES and PUBLICATION 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: the legal representatives of the Family. I have also sent it to Kennedys LLP on behalf of the Princess Alexandra Hospital NHS Foundation Trust, and to the Care Quality Commission who may find It useful or of interest. I am under a duty to send a copy of your response to the Chief Coroner. The Chief Coroner may publish either or both in a complete or redacted or summary form. She 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. 9 Dated: 19/05/2025 Thea WILSON HM Assistant Coroner for ESSEX Regulation 28 – After Inquest Document Template Updated 30/07/2021
1 response 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.
The Princess Alexandra Hospital Hamstel Road Harlow Essex CM20 1QX 22 July 2025 Assistant Coroner Thea Wilson Essex Coroner’s Court Chelmsford County Hall Victoria Road Chelmsford CM1 1QH Dear Ms Wilson, Thank you for providing us the opportunity to respond to your Regulation report dated 19 May 2025. Firstly, we would like to convey our sincere condolences to Baby Emmy’s family. The maternity service agrees that there were missed opportunities to have delivered Baby Emmy sooner for which it is truly sorry. We note that two areas of concern which you raised, and will respond to these in turn. The evidence of the current information given to patients at 40 weeks’ pregnant on the decision over whether to accept the offer of an induction from 41 weeks does not reflect NICE guidance on the information needed by patients to make an informed choice on induction. Whilst it provides details of the risks associated with induction, it does not provide information on the risks of continuing with pregnancy beyond 41 weeks. 01 As discussed at Inquest, the Maternity Service developed a new patient Information Leaflet in November 2024 concerning Induction of Labour. It was, however, recognised through the course of the Inquest that the leaflet required more specific details of the risks of continuing pregnancy beyond 41 weeks (including stillbirth, neonatal death and increase risk of admission to Neonatal Unit (NNU)) in order to allow informed decision making. It was also recognised that there needed to be a move from overemphasis that inductions can be prolonged and painful. 02 A multidisciplinary task group was subsequently established to complete these amendments. This group consisted of Obstetricians, Midwives, Governance Leads and representatives from the Maternity and Neonatal Voices Partnership in order to ensure that language was clinically accurate and accessible to service users. 03 The final version was published on 16 June 2025 and is appended to this letter. This updated leaflet explicitly sets out the risks as set out at paragraph 1 of this statement. 04 In addition to the above, and whilst the above leaflet was being developed, the Maternity Leadership held a meeting immediately following the conclusion of the Inquest to inform all witnesses and the senior leadership (including the Director of Quality and Assurance for the Trust) to address the concerns raised. 05 Immediate action also consisted of persistent and consistent messaging in daily staff huddles and discussion at the Maternity Unit Meeting held on 29 May 2025. 06 In regards to future plans, the Trust plans to implement regular audits of antenatal records of Induction of Labour discussions. It is anticipated that these audits will take place from October 2025, once the new Patient Information Leaflet has fully been embedded. In the interim, snap Audits will take place to monitor compliance. 07 Audit findings will be shared with the Divisional Board and Service User Forums for assurance and transparency. 08 Feedback will also be collected via the Maternity and Neonatal Voices Partnership and antenatal clinic surveys to further monitor implementation. 10 Whilst we understand that the above concern was directed at ensuring that patients are informed the risks of prolonged gestation in particular, the Trust continues to work with Birthrights to provide training to clinicians. As discussed at Inquest, Birthrights is an organisation focused on supporting patients right to choose and enabling individuals to make informed decisions about their care. The Trust plans to make this training mandatory for all Consultants, resident doctors and Midwives, with a view to start in January 2026, having been optional to this point. The evidence given at inquest indicated a lack of understanding and/or consistency over when concerns about labouring mothers and/or the CTG trace should be escalated for doctor review. Evidence was given on the measures put in place to address issues with escalation, including “Teach or Treat” and “AID” tools, however, there was limited evidence that these are understood by the working midwives and/or advertised to them by way of regular reminders. 11 The work to continue embedding the appropriate and consistent use of escalation tools continues with a commitment from Senior Leadership Team (SLT) to champion these and emphasise their importance to patient safety. 12 This has including a relaunch of the ‘Teach or Treat’ and AID tools with posters and quick reference messages being distributed across clinical areas including the labour ward, handover room and staff areas. 13 In regards to training, this is not only provided to new starters in the form of dedicated escalation training but also is regularly revisited by existing staff. These tools form part of the mandatory fetal monitoring teaching days which take place annually. Refreshers are also provided post incidents and when applicable, form part of the weekly case based learning reviews which are led by the Fetal Monitoring team every Monday. Learning points from these meetings are displayed on the Fetal Monitoring noticeboard and shared electronically. 14 In addition to this, the Trust is currently hiring a Labour Ward, Obstetric and Simulation Lead. As part of this role, the Consultant Obstetrician appointed will be responsible for providing simulations to the team which will include issues of both CTG interpretation and escalation. 15 On a day-to-day basis, these escalation criteria are routinely and regularly reinforced in daily safety huddles and actively encouraged in Labour Ward Obstetric Consultant rounds. 16 The Trust recognises the cultural and psychological factors in implementing these tools. In order to embed this practice, SLT has committed some Continuous Professional Development (CPD) towards “Active Bystander” training and embedding the “Civility Saves Lives” campaign at the Trust. funding 17 Further to this, the Trust is actively participating in the Labour Ward Coordinator Education and Development Framework. This is a national programme, focused on strengthening the leadership of Labour Ward Coordinators. The framework aims to enhance the quality of care provided in Labour Wards and will strengthen clinicians skills to escalate care appropriately. Whilst we acknowledge that completion of these actions will take time and are a continuous process, we are pleased to confirm that the wheels are already in motion and would be keen to provide further updates to the Coroners Service in due course. Please do not hesitate to contact me if you require any further details. Your sincerely, Chief Medical Officer Designate
See every Prevention of Future Deaths report matching The Princess Alexandra Hospital NHS Trust, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.