Dear Ms Mutch,

Re: Regulation 28 Report to Prevent Future Deaths

Thank you for your Regulation 28 Report dated 20th July 2023 concerning the sad death of Elliott James Harratt on the 29th of January 2023. On behalf of NHS Greater Manchester Integrated Care (NHS GM), We would like to begin by offering our sincere condolences to Mr Harratt’s family for their loss.

Thank you for highlighting your concerns during baby Harratt’s Inquest which concluded on the 26th of June 2023. On behalf of NHS GMICB, we apologise that you have had to bring these matters of concern to our attention. We recognise it is very important to ensure we make the necessary improvements to the quality and safety of future services.

Following the inquest, you raised concerns in your Regulation 28 Report to NHS GM that there is a risk a future death will occur unless action is taken. The medical cause of death was Extreme Prematurity.

I hope the response below demonstrates to you and baby Harratt’s family that NHS GM has taken the concerns you have raised seriously and will learn from this as a whole system.

This letter addresses the issues that fall within the remit of NHSGM and how we can share the learning from this case.

The inquest heard evidence that the rhesus status of Elliott’s mum meant that after a sensitising event Anti D needed to be given to prevent Rhesus disease in a newborn baby. The evidence before the inquest was that the type of events that would constitute a sensitising event and what action was then required were not made clear to Elliott’s mum. In addition, the type of events where a call to maternity triage for advice were not made clear to his mum.

This was, the evidence suggested, because there was no readily accessible or consistent list given to expectant mothers at booking in appointments or at follow up signposting them. Such a document in the form of a handout laminate or as a list in the handheld notes would increase awareness of events where a call to maternity triage would be advisable for health of both the mother and baby enabling health professionals to intervene at the earliest possible stage

Every patient is offered an ultrasound scan at around 10 to 14 weeks of pregnancy. This is called the dating scan. It's used to see how far along the patient is in their pregnancy and check the baby's development. The scan may also be part of a screening test for Down's syndrome.

4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk

There is a second (anomaly) scan at 18-21 weeks where they check for structural abnormalities in the baby. Further scans can be offered depending on health and pregnancy.

At these appointments the clinicians discuss any potential risks such as the mother having D blood type (previously known as “Rhesus D”, “RhD” or “Rhesus”), and it is also an opportunity to answer any questions and provide both verbal and written information in relation to what to do if there are any concerns about the baby or the mother.

If a mother has D blood type, this is discussed at the 18-21 week scan to ensure that the mother is aware of their status. They are also given written information on this. The written information is produced by NHS Blood and Transplant:
• Blood Groups and Red Cell Antibodies in Pregnancy – NHS Blood and Transplant leaflet

red-cell-antibodies-in-pregnancy.pdf
• Protecting women and babies with anti-D Immmunoglobulin – NHS Blood and Transplant leaflet

Each of our Trusts in Greater Manchester that provide maternity services are set up slightly differently in relation to how they deliver services, however the advice they provide to mothers on when to contact services is consistent across the system and comes in many forms, written, verbal and online.

We will use this event as an opportunity to highlight the importance of ensuring that mothers who do have D blood type, have the appropriate guidance, written information and understand when to contact services.

Actions taken or being taken to share learning across Greater Manchester:

1. Learning to be presented/shared with the Greater Manchester System Quality Group on the 16th of November 2023. This meeting is attended by a broad range of system leaders including clinical and care leaders, commissioners of specialist services, locality representatives from each of the 10 GM boroughs, the CQC, Healthwatch who represent the public voice and NICE. Through sharing in this forum, we expect members to review and ensure learning is incorporated into their commissioned services.
2. As part of our approach to embedding the learning we share the learning from this and similar cases at Greater Manchester and borough level. This is cascaded to professionals through relevant governance and learning forums to ensure that learning is incorporated into their services. In this case it will be discussed at the Local Maternity and Neonatal Network Safety Assurance Panel on the 5th of October 2023.

In conclusion, key learning points and recommendations will be monitored to ensure they are embedded within practice. NHS GM is committed to improving outcomes for the population of Greater Manchester.

We hope this response demonstrates to you and baby Harrat’s family that NHS GM has taken the concerns you have raised seriously and is committed to working together as a system including our service users, carers and families to improve the care provided.

Thank you for bringing these important patient safety issues to our attention and please do not hesitate to contact us should you need any further information.

4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk