Zachary Taylor-Smith
PFD Report
All Responded
Ref: 2024-0152
All 1 response received
· Deadline: 9 May 2024
Coroner's Concerns (AI summary)
Staff lacked critical understanding of neonatal deterioration and infection risks, exacerbated by poor communication between maternity and neonatal teams, and inadequate systems for patient reviews and capacity assessment for inductions.
View full coroner's concerns
I heard evidence that the Trust are committed to improvement and have already made and are planning to make important improvements. However, I remain concerned in relation to the following matters:
a. Staff lacking appreciation and proper understanding of the significance of the four hour period after birth in relation to indicators of a deteriorating baby and the potential over emphasis placed on the possible innocuous explanation for grunting in that period.
b. Staff lacking appreciation of the significance of the timing between rupture of membranes in a pre-term birth and birth and therefore failing to note or ask to be furnished with that information to inform their assessment of the risks of infection in babies.
c. The persisting cultural issues affecting the relationships and communication between maternity and neonatal staff. Given that the responsibility for checking and monitoring signs of infection in the newborn was not, from the evidence, placed on either the midwifery team or the neonatologists but was a joint one, the relationship that exists between the teams is of critical importance.
d. Absence of an effective system in place to ensure required reviews remain live until completed.
e. Absence of a formal mechanism for reviewing whether it is safe for planned inductions to take place in the context of ward and neonatal units levels of activity and capacity.
a. Staff lacking appreciation and proper understanding of the significance of the four hour period after birth in relation to indicators of a deteriorating baby and the potential over emphasis placed on the possible innocuous explanation for grunting in that period.
b. Staff lacking appreciation of the significance of the timing between rupture of membranes in a pre-term birth and birth and therefore failing to note or ask to be furnished with that information to inform their assessment of the risks of infection in babies.
c. The persisting cultural issues affecting the relationships and communication between maternity and neonatal staff. Given that the responsibility for checking and monitoring signs of infection in the newborn was not, from the evidence, placed on either the midwifery team or the neonatologists but was a joint one, the relationship that exists between the teams is of critical importance.
d. Absence of an effective system in place to ensure required reviews remain live until completed.
e. Absence of a formal mechanism for reviewing whether it is safe for planned inductions to take place in the context of ward and neonatal units levels of activity and capacity.
Responses
Action Taken
The hospital has implemented several changes, including mandatory training for maternity staff on CTG interpretation, a new fetal monitoring standard, daily safety huddles, and dedicated maternity flow coordinators. They have also updated their internal escalation policy for maternity and neonatal services. (AI summary)
The hospital has implemented several changes, including mandatory training for maternity staff on CTG interpretation, a new fetal monitoring standard, daily safety huddles, and dedicated maternity flow coordinators. They have also updated their internal escalation policy for maternity and neonatal services. (AI summary)
View full response
Dear Madam
Zachary Taylor-Smith: Regulation 28 Report Response
I am writing in response to the Regulation 28 Report dated 14 March 2024, following the Inquest into Zachary Taylor-Smith's sad death.
Conscious that Zachary's family will receive a copy of this response, I firstly want to begin by offering my deepest condolences to his parents and family. I am sorry the care we delivered to Zachary and his parents was not as it should have been.
We are determined to ensure the care our families receive is of the highest quality and our staff can deliver good quality care at all times. As such, our Women and Children's Division staff have collated the specific responses Zachary's case, but I also write to provide further assurance on the actions we continue to take, including through our wider Maternity & Neonatal Improvement Programme.
As a Trust we welcome working closely with our families, and having benefitted from Zachary's parents' continued engagement, I also wish to acknowledge and give thanks for their ongoing work with us over what are incredibly difficult events.
Scope
With our commitments to improve, the investments we have made, and the scale of the Maternity & Neonatal Improvement Programme, we note the matters of concern from the Regulation 28 Report, namely:-:
1. Staff lacking appreciation and proper understanding of the significance of the 4-hour period after birth in relation to indicators of a deteriorating baby and the potential over emphasis placed on the possible innocuous explanation for grunting in that period.
2. Staff lacking appreciation of the significance of the timing between rupture of membranes in a pre- term birth and birth and, therefore, failing to note or ask to be furnished with that information to inform their assessment of the risks of infection in babies.
3. The persisting cultural issues affecting the relationships and communication between maternity and neonatal staff.
4. Absence of an effective system in place to ensure required reviews remain live until completed.
5. Absence of a formal mechanism for reviewing whether it is safe for planned inductions to take place in the context of ward and neonatal units levels of activity and capacity.
Trust Response
Please find enclosed commentary that has been prepared to give assurance on the actions taken to address the points of concern you have raised and following the Regulation 28 Report.
Appendix 1 (attached) is the action plan which documents the actions already taken and those in progress. These include actions generated because of our internal investigations into Zachary's death, and additional actions because of your findings following Zachary's Inquest. This action plan creates a single location whereby actions can be monitored, and evidence of completion embedded, with continual review to maintain assurance into the longer term.
The Trust has over the last 2 years committed significant time and resource into improving the safety of care delivery in our maternity services. Internal and external reviews and reports have helped us identify our areas for focus. The extensive Maternity & Neonatal Improvement Programme in progress includes investment in additional staff, improved equipment and facilities, as well as embedding improvements to system and process. We have also strengthened the leadership roles we have to include the recently newly appointed Director of Midwifery, Divisional Director of Operations, and Divisional Medical Director with a Divisional Director of Nursing who has been in post for just over a year. We acknowledge that whilst we have already delivered on positive change, we are not complacent and are committed to acting openly and honestly, examining all the facts and with the determination to deliver improvements for future care. As such, in addition to individual incident reviews, we have proactively requested and welcomed reviews into our services, which are informing our work and delivering demonstrable improvements. We have also appointed 46 additional midwives and increased our medical establishment across obstetrics and anaesthetics.
The Maternity & Neonatal Improvement Programme contains 14 broad workstreams. Each workstream has its own clinical lead, project lead and operational lead that drive forward actions with set milestones, which are then monitored by the Board. Our patient experience manager also provides feedback received from our patient population into each workstream alongside input from our Maternity Voices and Neonatal Partnership Group.
The Trust is also working closely with NHS England and we are the only Trust that have proactively asked to enter the National Maternity Safety Support Programme. This provides the Trust with additional senior expertise/consultants through two Maternity Improvement Advisors: a very senior midwife/Director of Midwifery equivalent and an Obstetric Consultant. Their role is to give independent advice, verification/and or escalation of risks alongside the Trust to the Regional Chief Midwife, the ICB and the CQC which monitor progress of the Maternity & Neonatal Improvement Programme through the Regional Oversight Meeting.
I hope that this response demonstrates that the Trust is committed to making changes following Zachary's tragic death and to improving care for our future patients.
Zachary Taylor-Smith: Regulation 28 Report Response
I am writing in response to the Regulation 28 Report dated 14 March 2024, following the Inquest into Zachary Taylor-Smith's sad death.
Conscious that Zachary's family will receive a copy of this response, I firstly want to begin by offering my deepest condolences to his parents and family. I am sorry the care we delivered to Zachary and his parents was not as it should have been.
We are determined to ensure the care our families receive is of the highest quality and our staff can deliver good quality care at all times. As such, our Women and Children's Division staff have collated the specific responses Zachary's case, but I also write to provide further assurance on the actions we continue to take, including through our wider Maternity & Neonatal Improvement Programme.
As a Trust we welcome working closely with our families, and having benefitted from Zachary's parents' continued engagement, I also wish to acknowledge and give thanks for their ongoing work with us over what are incredibly difficult events.
Scope
With our commitments to improve, the investments we have made, and the scale of the Maternity & Neonatal Improvement Programme, we note the matters of concern from the Regulation 28 Report, namely:-:
1. Staff lacking appreciation and proper understanding of the significance of the 4-hour period after birth in relation to indicators of a deteriorating baby and the potential over emphasis placed on the possible innocuous explanation for grunting in that period.
2. Staff lacking appreciation of the significance of the timing between rupture of membranes in a pre- term birth and birth and, therefore, failing to note or ask to be furnished with that information to inform their assessment of the risks of infection in babies.
3. The persisting cultural issues affecting the relationships and communication between maternity and neonatal staff.
4. Absence of an effective system in place to ensure required reviews remain live until completed.
5. Absence of a formal mechanism for reviewing whether it is safe for planned inductions to take place in the context of ward and neonatal units levels of activity and capacity.
Trust Response
Please find enclosed commentary that has been prepared to give assurance on the actions taken to address the points of concern you have raised and following the Regulation 28 Report.
Appendix 1 (attached) is the action plan which documents the actions already taken and those in progress. These include actions generated because of our internal investigations into Zachary's death, and additional actions because of your findings following Zachary's Inquest. This action plan creates a single location whereby actions can be monitored, and evidence of completion embedded, with continual review to maintain assurance into the longer term.
The Trust has over the last 2 years committed significant time and resource into improving the safety of care delivery in our maternity services. Internal and external reviews and reports have helped us identify our areas for focus. The extensive Maternity & Neonatal Improvement Programme in progress includes investment in additional staff, improved equipment and facilities, as well as embedding improvements to system and process. We have also strengthened the leadership roles we have to include the recently newly appointed Director of Midwifery, Divisional Director of Operations, and Divisional Medical Director with a Divisional Director of Nursing who has been in post for just over a year. We acknowledge that whilst we have already delivered on positive change, we are not complacent and are committed to acting openly and honestly, examining all the facts and with the determination to deliver improvements for future care. As such, in addition to individual incident reviews, we have proactively requested and welcomed reviews into our services, which are informing our work and delivering demonstrable improvements. We have also appointed 46 additional midwives and increased our medical establishment across obstetrics and anaesthetics.
The Maternity & Neonatal Improvement Programme contains 14 broad workstreams. Each workstream has its own clinical lead, project lead and operational lead that drive forward actions with set milestones, which are then monitored by the Board. Our patient experience manager also provides feedback received from our patient population into each workstream alongside input from our Maternity Voices and Neonatal Partnership Group.
The Trust is also working closely with NHS England and we are the only Trust that have proactively asked to enter the National Maternity Safety Support Programme. This provides the Trust with additional senior expertise/consultants through two Maternity Improvement Advisors: a very senior midwife/Director of Midwifery equivalent and an Obstetric Consultant. Their role is to give independent advice, verification/and or escalation of risks alongside the Trust to the Regional Chief Midwife, the ICB and the CQC which monitor progress of the Maternity & Neonatal Improvement Programme through the Regional Oversight Meeting.
I hope that this response demonstrates that the Trust is committed to making changes following Zachary's tragic death and to improving care for our future patients.
Sent To
- University Hospitals of Derby and Burton NHS Foundation Trust
Response Status
Linked responses
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56-Day Deadline
9 May 2024
All responses received
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Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 24 November 2022 I commenced an investigation into the death of Zachary Victor TAYLOR-SMITH aged Less than 1 day. The investigation concluded at the end of the inquest on 12 March 2024. The conclusion of the inquest was that: Zachary Taylor-Smith (Zac) was born and died on the 17th of November 2022 at The Royal Derby Hospital. His birth had been induced preterm due to maternal health complications. During birth Zac contracted an infection. After birth his condition quickly deteriorated and he died at just 14 hours old. His death was contributed to by neglect in that:
1. Despite being clinically indicated Zac’s mother was not offered intra partum prophylactic antibiotics at any time during the induction process by either the attending doctors or midwives.
2. The fact that Zac was born more than 18 hours after the rupture of his mother’s membranes was not recognised at any time after birth and therefore its significance in relation to the risk of early onset neonatal infection was missed and antibiotics were therefore not considered when they should have been.
3. Despite Zac showing persistent signs of respiratory distress and having feeding difficulties, both clinical indicators of early onset infection, he was not given antibiotics as he should have been in accordance with the hospital’s own and national guidance.
1. Despite being clinically indicated Zac’s mother was not offered intra partum prophylactic antibiotics at any time during the induction process by either the attending doctors or midwives.
2. The fact that Zac was born more than 18 hours after the rupture of his mother’s membranes was not recognised at any time after birth and therefore its significance in relation to the risk of early onset neonatal infection was missed and antibiotics were therefore not considered when they should have been.
3. Despite Zac showing persistent signs of respiratory distress and having feeding difficulties, both clinical indicators of early onset infection, he was not given antibiotics as he should have been in accordance with the hospital’s own and national guidance.
Circumstances of the Death
Zachary Taylor-Smith died on the 17th of November 2022 at Royal Derby Hospital. He was born after a planned induction of labour at 36 weeks. His mother was not given prophylactic antibiotics before birth as she should have been. Both the labour and neonatal wards were busy. Zac was born more than 18 hours after his mother’s membranes were artificially ruptured however the significance was not noted by either the midwife supporting the birth, or any professional involved in her care thereafter. Although signs of grunting and respiratory distress, which warranted a review, were escalated to the neonatal team, no neonatal review took place. The requirement for such Regulation 28 – After Inquest CONTROLLED Document Template Updated 30/07/2021
review was not communicated to the incoming neonatology team at the point of handover. Despite Zac showing persistent signs of respiratory distress and having feeding difficulties, both clinical indicators of early onset infection, he was not given antibiotics as he should have been in accordance with the hospital’s own and national guidance. There was evidence of confusion about the significance of the four hour period after birth in relation to indicators of a deteriorating baby and the potential over emphasis placed on the possible innocuous explanation for grunting in that period. Evidence was heard at the inquest about the culture that existed between the midwifery team and neonatologists and that their relationship was difficult, albeit it was not thought to have compromised Zac’s care. Given that the responsibility for checking and monitoring signs of infection in the newborn was not, from the evidence, placed on either the midwifery team or the neonatologists but was a joint one, the relationship that exists between the teams is of critical importance.
review was not communicated to the incoming neonatology team at the point of handover. Despite Zac showing persistent signs of respiratory distress and having feeding difficulties, both clinical indicators of early onset infection, he was not given antibiotics as he should have been in accordance with the hospital’s own and national guidance. There was evidence of confusion about the significance of the four hour period after birth in relation to indicators of a deteriorating baby and the potential over emphasis placed on the possible innocuous explanation for grunting in that period. Evidence was heard at the inquest about the culture that existed between the midwifery team and neonatologists and that their relationship was difficult, albeit it was not thought to have compromised Zac’s care. Given that the responsibility for checking and monitoring signs of infection in the newborn was not, from the evidence, placed on either the midwifery team or the neonatologists but was a joint one, the relationship that exists between the teams is of critical importance.
Copies Sent To
University Hospitals of Derby and Burton
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.