Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0236, written 21 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 | 21 May 2025 |
|---|---|
| Reference | 2025-0236 |
| Deceased | Etta-Lili Stockwell-Parry |
| Coroner | Kate Robertson |
| Coroner area | North West Wales |
| Category | Child Death (from 2015) · Hospital Death (Clinical Procedures and medical management) related deaths · Wales prevention of future deaths reports (2019 onwards) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Kate Robertson Senior Coroner for North West Wales REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Betsi Cadwaladr University Health Board (BCUHB) 1 CORONER I am Kate Robertson, HM Senior Coroner for North West Wales 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 20 May 2024 I commenced an investigation into the death of Etta-Lili Stockwell- Parry (DOB 3/7/23) who passed away on 7 July 2023 (having received a transfer from the Coronial jurisdiction where Etta passed away). The investigation concluded at the end of the inquest on 20 May 2025. A narrative conclusion was recorded with the cause of death as:- 1a Hypoxic ischaemic encephalopathy Etta Lili Stockwell-Parry was born at 40+13 gestational weeks on 3 July 2023 at 00:51 at Ysbyty Gwynedd in poor condition following an instrumental assisted birth. Etta was transferred later that day to Arrowe Park Hospital, Liverpool for specialist neonatal support where she passed away on 7 July 2023 as a result of inutero compromise which led to the condition from which she died. There were several opportunities not taken by those caring for Etta’s mother antenatally including at 40+1 gestational weeks and at 40+5 gestational weeks and at 40+12 gestational weeks to escalate from a midwife to a registrar due to static growth which would have led to induction of labour and likely safe delivery of Etta. There were opportunities to identify concerns with Etta through her mother on the midwifery led unit on 2 July 2023 including properly conducting holistic assessments, properly completing partogram and manual palpation of maternal pulse which would also likely have resulted in earlier detection of distress and successful delivery. Etta’s death was contributed to by neglect. Coroner's Office, Shirehall Street, Caernarfon 4 CIRCUMSTANCES OF THE DEATH The circumstances of the death are as follows :- Etta was born in poor condition at Ysbyty Gwynedd on 3 July 2023 where her Mother’s pregnancy was uneventful up until 21 June 2023 (40+1 gestational weeks). Static growth had not been identified by the community midwife at this time and therefore there was no referral to obstetrics. The static growth was not identified for a second time at 40+5 gestational weeks on 25 June 2023. Again, there was no referral to obstetrics. When Etta’s mother was 40+12, on 2 July, she arrived at the Maternity Outpatient Assessment Unit for induction of labour. It was not noted that there was static growth. She ought to have been referred to the labour ward for close monitoring. Instead, she was induced. She received intermittent monitoring. The holistic assessments were not always completed and not entirely complete, the partogram did not note baseline fetal heart rate only as required, the maternal pulse was not always taken and recorded and there was no recognition that Etta’s mother’s pulse was being recorded as opposed to the fetal heart rate. There were in Etta’s mother’s care which resulted in several gross failures identified opportunities not taken to deliver Etta before she became distressed. Etta was transferred to Arrowe Park Hospital for specialist neonatal care where she passed away 4 days later. There were many incidences of learning from a neonatal perspective relating to Etta’s resuscitation at Ysbyty Gwynedd. 5 CORONER’S CONCERNS During the course of the inquest, the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows – The maternity and neonatal departments undertook an investigation into Etta’s mother’s care antenatally and after Etta’s delivery. The concerns are as follows:- a. The neonatal investigation was not thorough. The investigator did not obtain or request statements from doctors directly involved in Etta’s resuscitation, nor did they meet with them to understand what had occurred. The investigation was based on records alone. The records themselves, identified as part of the investigation, were often incomplete or included retrospective entries. Despite this, the investigator nor the panel involved considered speaking to or obtaining statements from crucial individuals. Coroner's Office, Shirehall Street, Caernarfon b. There was no sufficiently full contextual sharing of the investigation or its findings from a neonatal or maternity perspective. Some witnesses had only received and read the report several weeks prior to the Inquest. c. The memoranda sent to staff highlighting the learning did not include context or narrative around the circumstances of investigation. Therefore, those not directly involved would not have been fully aware of the context of what had occurred. Having issued Reports to the Health Board regarding quality of investigation previously, this concern remains. Specifically, I have concerns that the neonatal element of the investigation was not thorough enough such that without this genuine learning and change will not and cannot occur. Even where learning has been shared, I am concerned that this is not contextualised sufficiently. I am also concerned that staff not involved in the incident will not learn fully enough from events where there is inadequate sharing of learning from an incident. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you 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 16 July 2025. I, Kate Robertson, the Coroner, may extend the period. 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. 8 COPIES and PUBLICATION I have sent a copy of my report to Etta’s family and to the Chief Coroner. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He 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 by the Chief Coroner. 9 Dated 21 May 2025 Coroner's Office, Shirehall Street, Caernarfon Signature Kate Robertson HM Senior Coroner for North West Wales Coroner's Office, Shirehall Street, Caernarfon
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.
Bloc 5, Llys Carlton, Parc BusnesLlanelwy, Llanelwy, LL17 0JG ---------------------------------- Block 5, Carlton Court, St Asaph Business Park, St Asaph, LL17 0JG Ein cyf / Our ref: WINQ1875 Eichcyf / Your ref: : 03000 840135 Gofynnwch am / Ask for: Matthew Joyes E-bost / Email: matthew.joyes@wales.nhs.uk Dyddiad / Date: 16 July 2025 Kate Robertson HM Senior Coroner North Wales (West) HM Coroner’s Office Shirehall Street Caernarfon LL55 1SH Dear Ms Robertson, RE: REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Etta Lili Stockwell-Parry I am writing in response to the Regulation 28 Report to Prevent Future Deaths dated 21st May 2025, issued by yourself to Betsi Cadwaladr University Health Board, following the inquest touching the death of Etta Lili Stockwell-Parry. I would like to begin by offering my deepest condolences to the parents and family of Etta. I will be meeting Mr. & Mrs. Stockwell-Parry in September and I will personally apologise to them, listen to their experience and discuss what we have done and to learn from this tragic event. You found that Etta’s death in July 2023 was contributed to by neglect with several missed opportunities that may have changed the outcome. On behalf of the Health Board, I extend our deepest apologies to Mr. & Mrs. Stockwell-Parry and all those affected by this tragedy. In the notice, you highlighted your concern that the neonatal investigation was not thorough, and that there was insufficient contextual sharing of the investigation or its findings from a neonatal or maternity perspective. In addition, the memoranda sent to staff highlighting the learning did not include context or narrative around the circumstances of investigation. Following your findings, significant consideration has been given as to next steps. A group of senior nursing, midwifery, medical and patient safety staff met to draft a comprehensive response, and the Executive Director of Nursing and Midwifery (as our executive lead for patient safety) has provided leadership oversight. I understand you recently met with the Executive Director of Nursing and Midwifery in respect of investigation quality, and I hope this has given you some further assurances on the work we have undertaken and will continue to take forward. In relation to investigations, as you know this is an area of improvement I have prioritised. Last year, a new Integrated Concerns Policy was approved in June 2024 by the Board Cyfeiriad Gohebiaeth ar gyfer y Cadeirydd a'r Prif Weithredwr / Correspondence address for Chairman and Chief Executive: Swyddfa'r Gweithredwyr / Executives’ Office Ysbyty Gwynedd, Penrhosgarnedd Bangor, Gwynedd LL57 2PW Gwefan: www.pbc.cymru.nhs.uk / Web: www.bcu.wales.nhs.uk and implemented in September 2024. This new policy provides a single, integrated approach to incident, complaint and mortality reviews and investigations. The patient safety, complaint and mortality review teams are now working together as a more integrated hub to coordinate investigations, supported by a daily hub review meeting and a weekly clinical executive led meeting. A new training programme for investigating officers has been implemented. The new policy also requires that all those involved in an incident are engaged in the process including receiving the sharing of information. Although these changes came after Etta’s tragic death and subsequent investigation in 2023, they form the basis of improvements that has changed how the Health Board investigates serous matters now and into the future. Furthermore, work is being finalised to improve how learning is shared once a review or investigation is completed. A learning repository is being developed which is a key digital initiative designed to support our journey toward becoming a learning and self-improving organisation. This is believed to be the first of its kind in Wales. The system will serve as a centralised, searchable repository that integrates data from multiple sources databases such as Datix (for incident and complaints), Greatix (system of positive feedback for learning), Civica (for patient feedback), audits, mortality reviews and more. Staff will be able to access relevant learning content, receive targeted updates, and contribute their own feedback. It will capture learning from a wide range of sources - both structured and unstructured - including incident reports. It will ensure that all content is quality-checked and appropriately categorised, support version control and user subscriptions making it easy for staff to access relevant learning and for administrators to manage content effectively. It will improve ‘closing the loop’ by capturing feedback on how learning is applied in practice. It is being tested currently with further evaluation and staff engagement during summer and a plan to roll out across the Health Board from November 2025. The changes being made, such as the new Integrated Concerns Policy and new Learning Repository, are part of a range of interventions being made to fundamentally change how the Health Board operates with the intention of building a sustainable organisation for the future. I am also leading work to improve how the organisation functions as part of a programme called Foundations for the Future, and this will have a range of interventions of which the closer integration of women’s services and neonatal services will be an outcome. This will also improve the way investigations and learning is conducted across these two deeply interconnected services). Finally, I am also aware the Executive Director of Nursing and Midwifery has instigated a number of immediate safety changes following your notice. The first is a clear direction that investigations across women’s services and neonatal services will have a single investigation officer (as opposed to the practice that occurred in Etta’s case where separate reviews were undertaken and then brought together). This will directly address quality and consistency, in line with how all other services operate. In addition, a directive has been issued that investigations across women’s services will use the framework and templates within the Integrated Concerns Policy (as opposed to the PMRT tool which was used for Etta’s case). The national tool will continue to be used however investigations will follow the established Health Board format. We have also appointed a new quality governance officer into neonatal services which will ensure access to local specialist skills and capacity for investigations and reviews. I hope this letter sets out for you the actions we have taken to ensure the concerns raised by yourself are being addressed and mitigated. I will reiterate my commitment, and that of the Health Board, to fully address the concerns regarding investigations. I would be happy to meet with you and discuss the plans in more detail, or provide further information and assurance should that be helpful. Once again, I offer my deepest condolences to the parents and family of Etta. Yours sincerely ______________ Carol Shillabeer Prif Weithredwr/Chief Executive cc Angela Wood, Executive Director of Nursing and Midwifery Matthew Joyes, Deputy Director for Legal Services
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