Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Felix Burton Hartley who died on 19 February 2023.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 30 August 2024 concerning the death of Felix Burton Hartley on 19 February 2023. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Felix’s parents and family in these very sad circumstances. NHS England are keen to assure the family and the Coroner that the concerns raised about Felix’s care have been listened to and reflected upon.

Your Report raises concerns over the availability of on-call Neonatology Consultants over the weekend period and overnight and, specifically, the arrangements for on-call Consultant cover at University Hospitals Sussex NHS Foundation Trust, which covers two hospital sites. Relevant to NHS England’s remit, you have raised that there is no national guidance as to the time that an on-call Neonatology Consultant should be expected to attend hospital in the event of an emergency, and whether multiple sites can be covered by one on-call Consultant. All neonatal critical care units (including neonatal intensive care units) adhere to the national standards set out in the neonatal critical care service specification. The service specification references the following British Association of Perinatal Medicine (BAPM) standards for staffing for all levels of neonatal critical care units, for both neonatal intensive care units (‘NICUs’) and Local Neonatal Units (LNUs) and Special Care Units (SCUs). I note that you have also addressed your Report to the BAPM. To assist the Coroner and family, I have summarised the main guidance on staffing from the relevant BAPM standards:
• NICUs with more than 2500 intensive care days per annum should double tier 2 cover at night by adding a second experienced junior doctor or appropriately trained specialty doctor or an advanced neonatal nurse practitioner (ANNP). A consultant present and immediately available on NICU in addition to tier 2 staff would be an alternative.
• NICUs undertaking more than 4000 intensive care days per annum with onerous on call duties should consider having a consultant present in addition to tier 2 staff and immediately available 24 hours per day. National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

24 October 2024

• It is recommended that all NICUs implement consultant presence on the unit for at least 12 hours per day or more, as resources allow and depending on patient numbers and intensity.
• LNUs providing either more than 2000 respiratory care days or more than 750 intensive care days annually should provide a separate Tier 3 Consultant rota for the neonatal unit.
• All LNUs should ensure that all consultants on-call for the unit also have regular weekday commitments to the neonatal service. This is best delivered by a ‘consultant of the week’ system, and no consultant should undertake less than 4 ‘consultant of the week’ service weeks annually.
• In SCUs, there should be a Lead Consultant for the neonatal service. Trusts with more than one neonatal unit should have separate cover at each level of all levels of staffing during office hours and out of hours. NHS Trusts exercise their own policies for out of hours, on call response times. This is linked to the Terms and Conditions for all NHS Consultants. My colleagues in the South East have been asked to engage with University Hospitals Sussex NHS Foundation Trust and Sussex Health and Care Integrated Care Board on the concerns raised in your Report for assurance purposes. NHS England will also consider the Trust’s responses to your Report carefully in due course. I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Felix, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.

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

Dear Ms Andrews,

Many thanks for contacting the British Association of Perinatal Medicine (BAPM) about the sad death of Felix Hartley. We are unable to comment on the specifics of cases but we have considered the points in your letter raised in regards to guidance from BAPM.

The national terms and conditions for NHS consultants in England are set by NHS Employers and we have attached the latest version [Please see p18 and 40.] We have also attached A guide to Determining On-call Availability Supplements issued by the NHS Modernisation Agency (August 2004). There is no recommendation around the time required to be on site.

BAPM is an advisory, not an executive body. We have made some relevant recommendations that can form the basis for local guidance. It is the responsibility of individual trusts to implement their own processes in line with national guidelines.

In our Service and Quality Standards for Provision of Neonatal Care in the UK (November 2022) [Page 24] we recommend;

“For all levels of NNU [neonatal unit] it is not appropriate for a consultant to provide out of hours cover to two geographically separate sites simultaneously. Similarly, where a consultant or CCT holder is resident and there are less Tier 2 staff as a result, another consultant should provide Tier 3 cover (i.e. a single consultant cannot simultaneously cover at Tier 2 and Tier 3 if such cover is normally provided by two separate clinicians of appropriate training and experience).”

In a new document from November 2023 that was NOT in place at the time of this death, Consultant Working Patterns – A BAPM Report [page 5]

“Clinical service commitment during daytime clinical shifts and on calls is paramount. Any other service commitments must not prevent 24/7 immediate availability to the neonatal service including the provision of advice and, where required, in person attendance. In person attendance out of hours should always be within 30 minutes. Immediate availability of consultants will be dependent on the experience of resident Tier 2 staff, particularly in relation to airway skills. This may require resident consultant models in some instances. Local solutions for covering additional areas such as general paediatrics and neonatal transport will need to be robustly job-planned and risk assessed.”

We recognise the importance of addressing the issues raised and suggest that we send out a safety alert to our members and stakeholders drawing attention to these recommendations.

Should you require further details on any of the actions outlined or wish to discuss our response in greater detail, please do not hesitate to contact me directly.

Dear they

The current 12 month rolling Perinatal Mortality Rate (PMR) for the Princess Royal Hospital is 2.68/1000 births (up to and including July 2024) , and this is lower than the Trust PMR of
2.78, the South-East regional benchmark rate of 4.7 (June 2023), and the Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACE) National figure of 5.0 (July 2024). The 12-month rolling Neonatal Mortality Rate (NMR) for the Princess Royal Hospital is
0.89/1000 (up to and including July 2024), this is lower than the Trust NMR of 1.16,the South- East regional benchmark rate of 1.4 (June 2023) , and the MBRRACE National rate of 1.16. Neonatal deaths are reviewed at regional level and local data is benchmarked by MBRRACE. These reviews of neonatal deaths have not highlighted the availability of the Neonatal Consultant at the Princess Royal Hospital as contributory factor to neonatal deaths The outcomes for babies born at the Princess Royal Hospital over the last three years are in- line in terms of safe outcomes, and are monitored regularly by the Women and Children's Division, and centrally by the Trust: The results are shown in the following SPC (statistical process control) chartsz PRH Neonatal Deaths rolling 12m rate 01/21- 08/24-Princess Royal Hospital starting 01/01/21
3.5
3.0
2.5
2.0
1.5
1.0
0.5
0.0 ~ ~ ~ ~ ~ ~ ~~ ~ Nnn~~nnnn~SRR8 R R R R 8 8 R8 4~~ & & 4 5 2 2953?88 2 8 $ 2 92353388 2 8 {292353 8 8 2 8 & 8 $ ? 2 5 Mean Rolling 12 months rate per 1000 births Process limits Specia cause concern Special cause improvement Target cause neither PRH Perinatal Mortality Rate rolling 12m rate 01/21 08/2024-Princess Royal Hospital starting 01/01/21
7.0
6.0
5.0 40
3.0
2.0
0.0 ~ ~~~~ ~ ~ ~~ ~ ~ ~~nnnnnnnnn{nR R 8 R 8 8 R R R 8 R R & 4 ~ * &4 & ~ {292393{88 2 3$292393388 2 3 $292393388 289292393? Rolling 12 months rate per 1000 births Process limits Special cause concem Special cause improvement Target special cause neither 3 1 3 { special Mean

PRH HIE 2 & 3 Rate 12m rate 01/21 - 08/2024-Princess Royal Hospital starting 01/01/21
4.0
3.5
3.0
2.5
2.0 0,5 ~ ~~~~ ~ ~ ~~ ~ ~ ~~nnnnnnnnn{nR R 8 R 8 8 R R R 8 R R & 4 ~ * &4 & ~ {292393{88 2 3$292393388 2 3 $292393388 289292393? Rolling 12 months rate per 1000 births Process limits Special cause concem Special cause improvement Target special cause neither The Trust is aware that the current Neonatal Consultant on-call arrangements for the Trevor Mann Baby Unit and the Princess Royal Hospital Special Care Baby Unit do not meet the current British Association of Perinatal Medicine standards, but our review of outcomes did not find evidence that the current arrangements we have in place are unsafe. However, it is acknowledged that it is right to review these arrangements_ We are exploring the options for providing a separate Neonatal Consultant on-call rota for the Princess Royal Hospital Special Care Baby Unit_ but we do not have existing Consultant resources to meet this need_ The Trevor Mann Baby Unit Consultants are already fully committed clinically, and the workforce and financial resources are not currently available to fund the large Consultant expansion that would be needed to provide freestanding Princess Royal Hospital Special Care Baby Unit rota_ Therefore in view of the complexity and interdependency of the provision of maternity services the Trust is approaching the Integrated Care Board (ICB) to consider externally reviewing the current arrangements and the options for strengthening our Neonatal Consultant on-call arrangements for the Princess Royal Hospital Neonatal service_