Louie Bradley
PFD Report
All Responded
Ref: 2018-0261
All 2 responses received
· Deadline: 20 Nov 2018
Sent To
Response Status
Responses
2 of 1
56-Day Deadline
20 Nov 2018
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner’s Concerns
1. The midwives at your Hospital gave evidence that they still advise breastfeeding in bed whilst lying side-by-side with the baby even if no-one else is present and the mother is obviously fatigued, this leads to inadvertent co-sleeping and as in this case can lead to death.
2. The standard Trust issue documentation was not (properly) completed with the omission of vital information such as mother’s name, GP Practice, address etc.; similarly advice allegedly given to patient was not documented.
2. The standard Trust issue documentation was not (properly) completed with the omission of vital information such as mother’s name, GP Practice, address etc.; similarly advice allegedly given to patient was not documented.
Responses
Response received
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Dear Mr Pollard Re: Louie Francis Bradley Re: Regulation 28 Report to Prevent Future Deaths am writing in response to your Regulation 28 Report to Prevent Future Deaths, issued following the Inquest touching the death of Louis Francis Bradley on 15 August 2018. May take this opportunity to extend my deepest sympathy to Mr & Mrs Bradley for their loss and appreciate this will remain a very difficult time for them and their family: am now in a position to respond to your concerns as outlined in Section 5 of your report. Section 5 (1) and (2) am aware that during the course of establishing how Louise came about his death you raised concerns about mothers choosing to bed share with their babies while breastfeeding Following receipt of the Regulation 28 Report, requested that the Head of Midwifery/Divisional Nurse Director and the Governance Lead for the Families Division review your concerns and would Iike to assure you that further actions in addition to the actions identified in the Serious Incident Report have been taken: have attached an Action Plan which details a number of improvements together with the relevant documentation which is in now place for your reference_ hope that my response has provided you and the family with the assurance that the Trust has taken appropriate action regarding safe sleeping advice and documentation Please do not hesitate to contact me in the event you require any further assistance Yours eincerely abe Zes Dr Jackie Bene Chief Executive Encl: Action Plan with supporting documentation
Response received
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Report Sections
Investigation and Inquest
On the 31st August 2017 I commenced an investigation into the death of Louie Francis Bradley, aged 1 day. The investigation concluded at the end of the inquest on the 15th August 2018. The conclusion of the inquest was that he died from Sudden and Unexpected Neo-Natal Death of an Infant born at 42 weeks with widespread pneumonia. The narrative conclusion was as follows:-
On the 27th August 2017 Louis Francis Bradley died as a result of a combination of Natural Disease (undiagnosed Bronchopneumonia and the symptoms of the common cold) and an accidental obstruction of his airways whilst in bed following a breastfeed.
On the 27th August 2017 Louis Francis Bradley died as a result of a combination of Natural Disease (undiagnosed Bronchopneumonia and the symptoms of the common cold) and an accidental obstruction of his airways whilst in bed following a breastfeed.
Circumstances of the Death
He died following breast feeding in bed with his mother when mother fell asleep.
Inquest Conclusion
-
On the 27th August 2017 Louis Francis Bradley died as a result of a combination of Natural Disease (undiagnosed Bronchopneumonia and the symptoms of the common cold) and an accidental obstruction of his airways whilst in bed following a breastfeed.
On the 27th August 2017 Louis Francis Bradley died as a result of a combination of Natural Disease (undiagnosed Bronchopneumonia and the symptoms of the common cold) and an accidental obstruction of his airways whilst in bed following a breastfeed.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.