Eddie Coffey
PFD Report
All Responded
Ref: 2020-0287
All 2 responses received
· Deadline: 4 Mar 2021
Response Status
Responses
2 of 2
56-Day Deadline
4 Mar 2021
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 Serious Incident Report prepared on behalf of East and North Hertfordshire NHS Trust concluded that the Investigation was unable to determine the factors that were directly responsible for the death of baby Eddie Coffey. This conclusion was directly contradicted by evidence at the inquest.
(2) Evidence was given at the inquest by a Consultant Obstetrician from Lister Hospital that there was a gross failure in the basic medical care provided in the monitoring and management of the foetal heart rate during the labour, and that but for that failure Eddie Coffey might have survived.
(3) Evidence was given at the inquest by an independent Consultant Obstetrician that there was a gross failure in the basic medical care provided in the monitoring and management of the foetal heart rate during the labour, and that but for that failure Eddie Coffey would more than likely have survived.
(4) It was not clear from the inquest that, despite training implemented by the Trust since the death, that the same situation would not arise again.
(5) The Evidence was given at the inquest by an independent Consultant Obstetrician that 100 maternity units in the country are following the wrong guidelines in relation to managing foetal heart rate monitoring in labour.
(2) Evidence was given at the inquest by a Consultant Obstetrician from Lister Hospital that there was a gross failure in the basic medical care provided in the monitoring and management of the foetal heart rate during the labour, and that but for that failure Eddie Coffey might have survived.
(3) Evidence was given at the inquest by an independent Consultant Obstetrician that there was a gross failure in the basic medical care provided in the monitoring and management of the foetal heart rate during the labour, and that but for that failure Eddie Coffey would more than likely have survived.
(4) It was not clear from the inquest that, despite training implemented by the Trust since the death, that the same situation would not arise again.
(5) The Evidence was given at the inquest by an independent Consultant Obstetrician that 100 maternity units in the country are following the wrong guidelines in relation to managing foetal heart rate monitoring in labour.
Responses
Response received
View full response
Dear Mr Stevens
Eddie Coffey (Deceased)
I am writing in response to your Regulation 28 report to Prevent Future Deaths, which was received 15 December 2020, regarding the above named. I was saddened to learn of the sad circumstances of Eddie’s death on 14 January 2019. I will answer each of your matters of concern in turn.
In relation to the first matter of concern, we are acutely aware that the conclusion of the Serious Incident (SI) investigation was contradicted by the evidence heard at the Inquest. The SI investigation report reflected the information provided by the relevant clinical staff and it was felt that it was a valid and accurate reflection on the care service delivery issues identified. As you know, as part of the SI investigation the Trust requested an external independent opinion on the CTG trace from . The scope of that opinion was limited to asking his opinion on what the CTG trace showed. I understand that as part of your Inquest you subsequently obtained a formal report from him that went into more depth and in turn brought with it further criticisms. When obtaining an independent third-party or independent clinical opinion in the future the trust will ensure this is done on a more formal basis with clear terms of reference.
The Trust is fully committed to learning from all SI investigations and part of the report includes a list of ‘recommendations’ that the author compiles in response to any ‘care / service delivery problems’ that the investigation has identified. It is the responsibility of the clinical team to prepare an action plan in response to those recommendations and to ensure learning from the incident. Action plans are developed by the multi-disciplinary clinical team and monitored through divisional governance meetings.
In addition, the Maternity team undertake peer reviews, resulting in transparency and ongoing oversight of action plans and learning across the Local Maternity and Neonatal System (LMNS). At monthly LMNS safety meetings all SI’s, actions and Quality Improvement (QI) projects from them along with the progress of embedding the QI are discussed. Furthermore, Lister Hospital Coreys Mill Lane Stevenage Hertfordshire SG1 4AB
Chief Executive: Trust Chair:
the Directors of Midwifery and the LMNS Programme Lead have agreed a standard operating procedure for LMNS oversight of SI investigations and action plans going forward.
Taking your second and third points together, we have noted the evidence given at the Inquest by the Trust’s Consultant Obstetrician and the independent Consultant Obstetrician. However, as also was discussed at the Inquest and stated in the ‘Saving Babies Lives’ bundle 2 (NHS England, March 2019), ‘CTG monitoring is a well-established method of confirming fetal wellbeing and screening for fetal hypoxia…However, CTG interpretation is a high-level skill and is susceptible to variation in judgement between clinicians and by the same clinician over time. These variations can lead to inappropriate care planning and subsequently impact on perinatal outcomes’. Differing interpretations of CTG recordings is therefore a recognised risk. In order to mitigate against this risk, the Trust is committed to enhancing our already well established Fetal Monitoring training, and in particular enhancing the training provided to staff with regards to the second stage of labour. The importance of this issue is highlighted in every Fetal Monitoring lecture as maternal pulse features and characteristics are included as well as being included in an element of the Human Factors training that is given. The intended impact of this is to ignite professional curiosity and to encourage clinicians to actively seek out to exclude maternal pulse. Furthermore, since 20 January 2020 the trust has employed a full time fetal monitoring specialist midwife for 12 months. This midwife provides specialist guidance, teaches staff about the physiological approach, works clinically on the unit reviewing CTG’s and leads on fetal monitoring education with the Consultant Obstetrician. As a result of the work described above, our internal fetal monitoring assessment which was introduced in 2019 has maintained a pass rate of 98%.
In response to your fourth point, actions have been developed to further strengthen the training in relation to second stage fetal monitoring interpretation. A second stage training update was delivered on 19 January 2021 which focussed on fetal monitoring and recognising the signs to differentiate between maternal pulse and fetal heart rate, highlighting learning from themes and incidents. Further sessions have been planned in this regard. An Intermittent Auscultation and escalation competency package, using added case scenarios including small group sessions and annual training, is being rolled out to the Midwifery-Led-Unit (MLU) midwives supported by a plan to role this out to all midwives. This will include a competency - based assessment and a requirement to record pass rates for ongoing auditing and assurance.
Notwithstanding the training that has been implemented already at the Trust, it is accepted that CTG technology is not straightforward. This has led to a review being undertaken of the CTG machines currently in use within the Trust. As a department, Maternity are working towards standardising equipment in line with best practice. Review of the CTG machines currently in use has identified that 6 new machines are required which would then mean that all of the machines in use are the same and all would record maternal pulse on the CTG trace. Further work towards the procurement of these machines is ongoing and being reviewed by our Capital Equipment Committee. This issue will be added to the risk register which will ensure oversight and enable clear monitoring on a regular basis.
Moreover, in terms of immediate practical steps taken, we are in the process of producing a visual sticker that will go at the front of a CTG machine after a woman is transferred from MLU to CLU. This sticker will include a box for two individuals to check and sign that they have independently palpated maternal pulse. This process will be in place by the end of February
2021.
We have also reviewed the emerging findings and recommendations from the first Ockenden Report in their ongoing review of Maternity Services at Shrewsbury and Telford Hospital Trust published in December 2020. As you may already be aware, one action in this report relates
Chief Executive: Trust Chair:
to CTG monitoring with a number of elements in relation to the management of CTG interpretation and escalation. We have planned for a number of actions going forward in order to ensure that we have a robust process in place in respect of these. Please see the attached excel spreadsheet for full sight of the CTG action plan, some of which are detailed above and the work is ongoing.
Lastly, I note your area of concern relating to why 100 maternity units in the country are following the wrong guidelines in relation to managing fetal heart rate morning following the evidence you heard from at the Inquest. I am aware that the Department of Health and Social Care will be responding to you on this point however I hope the contents of this letter demonstrates the relevant actions that the Trust have taken in relation to this.
I hope this letter demonstrates the commitment of East and North Hertfordshire NHS Trust to ensuring that we have learnt from this tragic incident and gives you the assurance that we have put a number of measures in place to mitigate against the risk of a recurrence. Our Maternity team are committed to providing the best possible care for women in our area and we continually strive to improve the services available.
Eddie Coffey (Deceased)
I am writing in response to your Regulation 28 report to Prevent Future Deaths, which was received 15 December 2020, regarding the above named. I was saddened to learn of the sad circumstances of Eddie’s death on 14 January 2019. I will answer each of your matters of concern in turn.
In relation to the first matter of concern, we are acutely aware that the conclusion of the Serious Incident (SI) investigation was contradicted by the evidence heard at the Inquest. The SI investigation report reflected the information provided by the relevant clinical staff and it was felt that it was a valid and accurate reflection on the care service delivery issues identified. As you know, as part of the SI investigation the Trust requested an external independent opinion on the CTG trace from . The scope of that opinion was limited to asking his opinion on what the CTG trace showed. I understand that as part of your Inquest you subsequently obtained a formal report from him that went into more depth and in turn brought with it further criticisms. When obtaining an independent third-party or independent clinical opinion in the future the trust will ensure this is done on a more formal basis with clear terms of reference.
The Trust is fully committed to learning from all SI investigations and part of the report includes a list of ‘recommendations’ that the author compiles in response to any ‘care / service delivery problems’ that the investigation has identified. It is the responsibility of the clinical team to prepare an action plan in response to those recommendations and to ensure learning from the incident. Action plans are developed by the multi-disciplinary clinical team and monitored through divisional governance meetings.
In addition, the Maternity team undertake peer reviews, resulting in transparency and ongoing oversight of action plans and learning across the Local Maternity and Neonatal System (LMNS). At monthly LMNS safety meetings all SI’s, actions and Quality Improvement (QI) projects from them along with the progress of embedding the QI are discussed. Furthermore, Lister Hospital Coreys Mill Lane Stevenage Hertfordshire SG1 4AB
Chief Executive: Trust Chair:
the Directors of Midwifery and the LMNS Programme Lead have agreed a standard operating procedure for LMNS oversight of SI investigations and action plans going forward.
Taking your second and third points together, we have noted the evidence given at the Inquest by the Trust’s Consultant Obstetrician and the independent Consultant Obstetrician. However, as also was discussed at the Inquest and stated in the ‘Saving Babies Lives’ bundle 2 (NHS England, March 2019), ‘CTG monitoring is a well-established method of confirming fetal wellbeing and screening for fetal hypoxia…However, CTG interpretation is a high-level skill and is susceptible to variation in judgement between clinicians and by the same clinician over time. These variations can lead to inappropriate care planning and subsequently impact on perinatal outcomes’. Differing interpretations of CTG recordings is therefore a recognised risk. In order to mitigate against this risk, the Trust is committed to enhancing our already well established Fetal Monitoring training, and in particular enhancing the training provided to staff with regards to the second stage of labour. The importance of this issue is highlighted in every Fetal Monitoring lecture as maternal pulse features and characteristics are included as well as being included in an element of the Human Factors training that is given. The intended impact of this is to ignite professional curiosity and to encourage clinicians to actively seek out to exclude maternal pulse. Furthermore, since 20 January 2020 the trust has employed a full time fetal monitoring specialist midwife for 12 months. This midwife provides specialist guidance, teaches staff about the physiological approach, works clinically on the unit reviewing CTG’s and leads on fetal monitoring education with the Consultant Obstetrician. As a result of the work described above, our internal fetal monitoring assessment which was introduced in 2019 has maintained a pass rate of 98%.
In response to your fourth point, actions have been developed to further strengthen the training in relation to second stage fetal monitoring interpretation. A second stage training update was delivered on 19 January 2021 which focussed on fetal monitoring and recognising the signs to differentiate between maternal pulse and fetal heart rate, highlighting learning from themes and incidents. Further sessions have been planned in this regard. An Intermittent Auscultation and escalation competency package, using added case scenarios including small group sessions and annual training, is being rolled out to the Midwifery-Led-Unit (MLU) midwives supported by a plan to role this out to all midwives. This will include a competency - based assessment and a requirement to record pass rates for ongoing auditing and assurance.
Notwithstanding the training that has been implemented already at the Trust, it is accepted that CTG technology is not straightforward. This has led to a review being undertaken of the CTG machines currently in use within the Trust. As a department, Maternity are working towards standardising equipment in line with best practice. Review of the CTG machines currently in use has identified that 6 new machines are required which would then mean that all of the machines in use are the same and all would record maternal pulse on the CTG trace. Further work towards the procurement of these machines is ongoing and being reviewed by our Capital Equipment Committee. This issue will be added to the risk register which will ensure oversight and enable clear monitoring on a regular basis.
Moreover, in terms of immediate practical steps taken, we are in the process of producing a visual sticker that will go at the front of a CTG machine after a woman is transferred from MLU to CLU. This sticker will include a box for two individuals to check and sign that they have independently palpated maternal pulse. This process will be in place by the end of February
2021.
We have also reviewed the emerging findings and recommendations from the first Ockenden Report in their ongoing review of Maternity Services at Shrewsbury and Telford Hospital Trust published in December 2020. As you may already be aware, one action in this report relates
Chief Executive: Trust Chair:
to CTG monitoring with a number of elements in relation to the management of CTG interpretation and escalation. We have planned for a number of actions going forward in order to ensure that we have a robust process in place in respect of these. Please see the attached excel spreadsheet for full sight of the CTG action plan, some of which are detailed above and the work is ongoing.
Lastly, I note your area of concern relating to why 100 maternity units in the country are following the wrong guidelines in relation to managing fetal heart rate morning following the evidence you heard from at the Inquest. I am aware that the Department of Health and Social Care will be responding to you on this point however I hope the contents of this letter demonstrates the relevant actions that the Trust have taken in relation to this.
I hope this letter demonstrates the commitment of East and North Hertfordshire NHS Trust to ensuring that we have learnt from this tragic incident and gives you the assurance that we have put a number of measures in place to mitigate against the risk of a recurrence. Our Maternity team are committed to providing the best possible care for women in our area and we continually strive to improve the services available.
Response received
View full response
Dear Mr Stevens
Thank you for your letter of 15 December 2020 to Matt Hancock about the death of Eddie John Coffey. I am responding as Minister with responsibility for maternity care.
Firstly, I would like to say how deeply sorry I was to read of the circumstances of baby Eddie’s death and I offer my most sincere condolences to Eddie’s parents and family. I appreciate how devastating it must be to lose a child and that the pain must be particularly hard to bear when there are concerns about the care provided.
It is essential that the East and North Hertfordshire NHS Trust (the Trust) takes all the learnings from the circumstances of Eddie’s death and the findings of your investigation to prevent future tragedies.
I am advised by the Care Quality Commission (CQC), the independent regulator for quality, that maternity services at the Trust were inspected in April 2018, resulting in an overall rating of Good and Requires Improvement for the safety of care. The CQC has monitored the improvements made by the Trust that include a move to physiological CTG interpretation1 supported by one full day of CTG training. The CQC was advised by the Trust that as at October 2020, 86 per cent of midwives and 73 per cent of medical staff had received additional training in fetal monitoring during labour.
I am further advised that an inspection of the Trust in June 2019 rated overall leadership as Requires Improvement reflecting that at that time, the Trust was developing its patient safety culture and strengthening its governance processes around incident management to ensure learning.
1 Physiological interpretation of cardiotocography. A technique used to monitor the fetal heart rate to assess fetal wellbeing.
I welcome the action that has been taken so far and I encourage the Trust to continue to look carefully at what more can be done to improve this important area of patient safety. In line with regulatory processes, I am assured that the CQC will continue to monitor improvements at the Trust and my officials have brought your report to the attention of health system leaders, NHS England and NHS Improvement (NHSEI).
To ensure patient safety, it is vitally important that NHS Trusts encourage a culture of openness and continuous learning. That is why, in 2017, the National Quality Board published national guidance on Learning from Deaths2, to introduce a more standardised approach to the way NHS trusts review, investigate and learn from deaths thought to be due to problems in care.
From 2017-18, we have required NHS trusts to publish locally the numbers of deaths thought to be due to problems in care on a quarterly basis, and to evidence what they have learned and the actions taken to prevent such deaths on an annual basis in their Quality Accounts. This new level of transparency is fundamental to a culture of learning and ensuring the safety of NHS services. This policy is supported by strengthened inspection assessment of NHS trusts’ learning from deaths by the independent regulator for quality, the CQC.
In relation to your findings about the quality of the Trust’s investigation of the care and treatment provided to Eddie Coffey and his mother during labour, you may wish to note that a new Patient Safety Incident Response Framework3, to replace the Serious Incident Framework, is being developed to facilitate examination of a wider range of patient safety incidents in the NHS and to improve the quality of patient safety incident investigation and how organisations can learn and change as a result.
The Framework outlines how NHS organisations should respond to patient safety incidents, including how and when an investigation should be conducted. The Framework supports a systematic, compassionate and proficient response; anchored in the principles of openness, fair accountability, learning and continuous improvement.
NHSEI is currently working with early adopters to pilot the new Framework. The learning from this pilot will be used to inform the final version of the Framework. Until this is finalized, NHS providers and their local health partners should review the introductory framework and Patient Safety Incident Investigation standards4 and begin to consider what they will need to do to support their implementation.
Turning to your wider concerns about maternity safety, I wish to assure you that there is much being done nationally to improve the quality and safety of maternity services.
2 https://www.england.nhs.uk/wp-content/uploads/2017/03/nqb-national-guidance-learning-from-deaths.pdf
3 https://www.england.nhs.uk/patient-safety/incident-response-framework/
4 https://www.england.nhs.uk/patient-safety/patient-safety-investigation/
Following the publication of first report, Emerging Findings and Recommendations from the Independent Review of Maternity Services at the Shrewsbury and Telford Hospitals NHS Trust, on 10 December 2020, NHSEI wrote to NHS Trust and Foundation Trust Chief Executives and Chairs5, setting out the immediate response required of all NHS Trusts providing maternity services and next steps to be taken nationally. Despite considerable progress having been made in improving maternity safety, there continues to be too much variation in experience and outcomes for women and their families.
This letter identifies seven priorities and has asked NHS Trusts for immediate actions to implement these, including: enhanced safety; listening to women and their families; staff training and working together; managing complex pregnancy; risk assessment throughout pregnancy; monitoring fetal wellbeing; and informed consent.
In relation to monitoring fetal wellbeing, NHS Trusts are being asked to implement the saving babies lives bundle. Element 4 of the Saving Babies Lives Care Bundle Version 2 (SBLCBv26) already states there needs to be one lead with the responsibility of improving the standard of fetal monitoring. NHS Trusts are now being asked to ensure that a second lead is identified so that every unit has a lead midwife and a lead obstetrician in place to lead best practice, learning and support. This will include regular training sessions, review of cases and ensuring compliance with the SBLCBv2 and national guidelines.
report also identified that safe delivery of maternity services is dependent on a multidisciplinary team approach. The Maternity Transformation Programme7, led by NHSEI, has implemented a range of interventions to increase numbers of healthcare professionals and support workers including the development of the maternity support worker role; the expansion of midwifery undergraduate numbers; additional maternity placements; and active recruitment.
In addition, £9.4million was awarded in the 2020 Spending Review to support maternity safety pilots that will include fresh learning from recent investigations and academic research to be used to improve clinical practice during childbirth, and cutting-edge training and expert guidance to improve practice and avoid harm to babies.
In relation to guidelines on monitoring fetal heart rate, there are different guidelines for fetal heart rate monitoring that NHS Trusts in England may refer to in developing their local guidelines. This includes:
• NICE (National Institute for Health and Care Excellence) ‘Intrapartum care for healthy women and babies’ Clinical guideline [CG1908] which includes guidelines on fetal monitoring in labour; and,
5 https://www.england.nhs.uk/wp-content/uploads/2021/01/Ockenden-Letter-CEO-Chairs-final-14.12.20-1.pdf
6 https://www.england.nhs.uk/wp-content/uploads/2019/07/saving-babies-lives-care-bundle-version-two- v5.pdf
7 https://www.england.nhs.uk/mat-transformation/
8 https://www.nice.org.uk/guidance/CG190
• FIGO (International Federation of Gynaecology and Obstetrics) ‘Consensus guidelines on intrapartum fetal monitoring: Cardiotocography9’.
In addition, there is a third approach called ‘Physiological CTG Interpretation’ developed by clinicians from St George’s Hospital, Lewisham and Greenwich NHS Trust and Kingston Hospital, led by
10. Part of the Spending Review 2020 investment of £9.4million is to pilot an approach to risk assessment and escalation of fetal deterioration, including fetal heart rate monitoring that can be standardised across all maternity providers in England.
Finally, my officials have brought your report to the attention of the Healthcare Safety Investigation Branch (HSIB). HSIB is a key part of our commitment to improve patient safety and the culture of learning in the NHS. The HSIB conduct independent maternity investigations that meet the Each Baby Counts criteria and a defined criteria for maternal deaths so that the NHS learns quickly from what went wrong and uses this to prevent future tragedies. Where HSIB identifies systemic risks, it can consider making national recommendations for system change.
I hope this response is helpful. Thank you for bringing these concerns to my attention.
NADINE DORRIES MINISTER OF STATE FOR PATIENT SAFETY, SUICIDE PREVENTION AND MENTAL HEALTH
9 https://www.figo.org/news/available-view-figo-intrapartum-fetal-monitoring-guidelines
10 https://www.icarectg.com/wp-content/uploads/2018/03/Intrapartum-Fetal-Monitoring-Guideline.pdf
Thank you for your letter of 15 December 2020 to Matt Hancock about the death of Eddie John Coffey. I am responding as Minister with responsibility for maternity care.
Firstly, I would like to say how deeply sorry I was to read of the circumstances of baby Eddie’s death and I offer my most sincere condolences to Eddie’s parents and family. I appreciate how devastating it must be to lose a child and that the pain must be particularly hard to bear when there are concerns about the care provided.
It is essential that the East and North Hertfordshire NHS Trust (the Trust) takes all the learnings from the circumstances of Eddie’s death and the findings of your investigation to prevent future tragedies.
I am advised by the Care Quality Commission (CQC), the independent regulator for quality, that maternity services at the Trust were inspected in April 2018, resulting in an overall rating of Good and Requires Improvement for the safety of care. The CQC has monitored the improvements made by the Trust that include a move to physiological CTG interpretation1 supported by one full day of CTG training. The CQC was advised by the Trust that as at October 2020, 86 per cent of midwives and 73 per cent of medical staff had received additional training in fetal monitoring during labour.
I am further advised that an inspection of the Trust in June 2019 rated overall leadership as Requires Improvement reflecting that at that time, the Trust was developing its patient safety culture and strengthening its governance processes around incident management to ensure learning.
1 Physiological interpretation of cardiotocography. A technique used to monitor the fetal heart rate to assess fetal wellbeing.
I welcome the action that has been taken so far and I encourage the Trust to continue to look carefully at what more can be done to improve this important area of patient safety. In line with regulatory processes, I am assured that the CQC will continue to monitor improvements at the Trust and my officials have brought your report to the attention of health system leaders, NHS England and NHS Improvement (NHSEI).
To ensure patient safety, it is vitally important that NHS Trusts encourage a culture of openness and continuous learning. That is why, in 2017, the National Quality Board published national guidance on Learning from Deaths2, to introduce a more standardised approach to the way NHS trusts review, investigate and learn from deaths thought to be due to problems in care.
From 2017-18, we have required NHS trusts to publish locally the numbers of deaths thought to be due to problems in care on a quarterly basis, and to evidence what they have learned and the actions taken to prevent such deaths on an annual basis in their Quality Accounts. This new level of transparency is fundamental to a culture of learning and ensuring the safety of NHS services. This policy is supported by strengthened inspection assessment of NHS trusts’ learning from deaths by the independent regulator for quality, the CQC.
In relation to your findings about the quality of the Trust’s investigation of the care and treatment provided to Eddie Coffey and his mother during labour, you may wish to note that a new Patient Safety Incident Response Framework3, to replace the Serious Incident Framework, is being developed to facilitate examination of a wider range of patient safety incidents in the NHS and to improve the quality of patient safety incident investigation and how organisations can learn and change as a result.
The Framework outlines how NHS organisations should respond to patient safety incidents, including how and when an investigation should be conducted. The Framework supports a systematic, compassionate and proficient response; anchored in the principles of openness, fair accountability, learning and continuous improvement.
NHSEI is currently working with early adopters to pilot the new Framework. The learning from this pilot will be used to inform the final version of the Framework. Until this is finalized, NHS providers and their local health partners should review the introductory framework and Patient Safety Incident Investigation standards4 and begin to consider what they will need to do to support their implementation.
Turning to your wider concerns about maternity safety, I wish to assure you that there is much being done nationally to improve the quality and safety of maternity services.
2 https://www.england.nhs.uk/wp-content/uploads/2017/03/nqb-national-guidance-learning-from-deaths.pdf
3 https://www.england.nhs.uk/patient-safety/incident-response-framework/
4 https://www.england.nhs.uk/patient-safety/patient-safety-investigation/
Following the publication of first report, Emerging Findings and Recommendations from the Independent Review of Maternity Services at the Shrewsbury and Telford Hospitals NHS Trust, on 10 December 2020, NHSEI wrote to NHS Trust and Foundation Trust Chief Executives and Chairs5, setting out the immediate response required of all NHS Trusts providing maternity services and next steps to be taken nationally. Despite considerable progress having been made in improving maternity safety, there continues to be too much variation in experience and outcomes for women and their families.
This letter identifies seven priorities and has asked NHS Trusts for immediate actions to implement these, including: enhanced safety; listening to women and their families; staff training and working together; managing complex pregnancy; risk assessment throughout pregnancy; monitoring fetal wellbeing; and informed consent.
In relation to monitoring fetal wellbeing, NHS Trusts are being asked to implement the saving babies lives bundle. Element 4 of the Saving Babies Lives Care Bundle Version 2 (SBLCBv26) already states there needs to be one lead with the responsibility of improving the standard of fetal monitoring. NHS Trusts are now being asked to ensure that a second lead is identified so that every unit has a lead midwife and a lead obstetrician in place to lead best practice, learning and support. This will include regular training sessions, review of cases and ensuring compliance with the SBLCBv2 and national guidelines.
report also identified that safe delivery of maternity services is dependent on a multidisciplinary team approach. The Maternity Transformation Programme7, led by NHSEI, has implemented a range of interventions to increase numbers of healthcare professionals and support workers including the development of the maternity support worker role; the expansion of midwifery undergraduate numbers; additional maternity placements; and active recruitment.
In addition, £9.4million was awarded in the 2020 Spending Review to support maternity safety pilots that will include fresh learning from recent investigations and academic research to be used to improve clinical practice during childbirth, and cutting-edge training and expert guidance to improve practice and avoid harm to babies.
In relation to guidelines on monitoring fetal heart rate, there are different guidelines for fetal heart rate monitoring that NHS Trusts in England may refer to in developing their local guidelines. This includes:
• NICE (National Institute for Health and Care Excellence) ‘Intrapartum care for healthy women and babies’ Clinical guideline [CG1908] which includes guidelines on fetal monitoring in labour; and,
5 https://www.england.nhs.uk/wp-content/uploads/2021/01/Ockenden-Letter-CEO-Chairs-final-14.12.20-1.pdf
6 https://www.england.nhs.uk/wp-content/uploads/2019/07/saving-babies-lives-care-bundle-version-two- v5.pdf
7 https://www.england.nhs.uk/mat-transformation/
8 https://www.nice.org.uk/guidance/CG190
• FIGO (International Federation of Gynaecology and Obstetrics) ‘Consensus guidelines on intrapartum fetal monitoring: Cardiotocography9’.
In addition, there is a third approach called ‘Physiological CTG Interpretation’ developed by clinicians from St George’s Hospital, Lewisham and Greenwich NHS Trust and Kingston Hospital, led by
10. Part of the Spending Review 2020 investment of £9.4million is to pilot an approach to risk assessment and escalation of fetal deterioration, including fetal heart rate monitoring that can be standardised across all maternity providers in England.
Finally, my officials have brought your report to the attention of the Healthcare Safety Investigation Branch (HSIB). HSIB is a key part of our commitment to improve patient safety and the culture of learning in the NHS. The HSIB conduct independent maternity investigations that meet the Each Baby Counts criteria and a defined criteria for maternal deaths so that the NHS learns quickly from what went wrong and uses this to prevent future tragedies. Where HSIB identifies systemic risks, it can consider making national recommendations for system change.
I hope this response is helpful. Thank you for bringing these concerns to my attention.
NADINE DORRIES MINISTER OF STATE FOR PATIENT SAFETY, SUICIDE PREVENTION AND MENTAL HEALTH
9 https://www.figo.org/news/available-view-figo-intrapartum-fetal-monitoring-guidelines
10 https://www.icarectg.com/wp-content/uploads/2018/03/Intrapartum-Fetal-Monitoring-Guideline.pdf
Report Sections
Investigation and Inquest
On 14th March 2019 Senior Coroner Geoffrey Sullivan commenced an investigation into the death of EDDIE JOHN COFFEY [age 1 day]. The investigation concluded at tie end of the inquest on 11th November 2020. The conclusion of the inquest was that Eddie Coffey died on 14th January 2019 at the Luton & Dunstable Hospital as a result of birth asphyxia during labour which was not property managed constituting neglect contributing to the cause of death. The medical cause of death was perinatal asphyxia.
Circumstances of the Death
Eddie Coffey was born at 23.27 on 19 January 2019 at Lister Hospital. On delivery he was in a poor state with a low heart rate and symptoms of hypoxia. He required resuscitation at birth. He was transferred to the Luton & Dunstable Hospital NICU for ongoing care. He died the next day on 14th January 2019.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.