Alissa Norton
PFD Report
All Responded
Ref: 2024-0108
All 1 response received
· Deadline: 22 Apr 2024
Coroner's Concerns (AI summary)
Crucial medical notes for the deceased baby were largely completed retrospectively by a midwife not directly involved in her care, with limited contemporary documentation. This resulted in inaccurate information for treating clinicians.
View full coroner's concerns
1. Alissa Claire Norton was born on 18 April 2022 at 39 + 5 weeks gestation at Worthing Hospital. At the time of and after Alissa’s birth there were two midwives present as per Trust Policy. One midwife was primarily looking after Mrs Norton and the other her daughter Alissa.
2. The evidence that I heard was that the majority of the notes which were adduced in evidence as to the events and treatment of Alissa were completed retrospectively on the next day (19 April 2022) by the midwife who cared for Mrs Norton. There were very limited notes completed by the midwife caring for Alissa at the time or at any time thereafter.
3. Therefore, there was limited documented information available to treating clinicians following Alissa’s birth as to the events and treatment which had been provided to her.
4. The inquest heard that some of the notes completed retrospectively were based on assumption rather than first hand knowledge. This was not clear in the notes.
2. The evidence that I heard was that the majority of the notes which were adduced in evidence as to the events and treatment of Alissa were completed retrospectively on the next day (19 April 2022) by the midwife who cared for Mrs Norton. There were very limited notes completed by the midwife caring for Alissa at the time or at any time thereafter.
3. Therefore, there was limited documented information available to treating clinicians following Alissa’s birth as to the events and treatment which had been provided to her.
4. The inquest heard that some of the notes completed retrospectively were based on assumption rather than first hand knowledge. This was not clear in the notes.
Responses
Action Taken
The trust shared messages on record keeping, audited maternity records, and took individual action with involved midwives. (AI summary)
The trust shared messages on record keeping, audited maternity records, and took individual action with involved midwives. (AI summary)
View full response
Dear Ms Andrews
Response to the Regulation 28: Report to Prevent Future Deaths following the Inquest touching upon the death of Alissa Norton.
This letter is to outline the actions taken by University Hospitals Sussex NHS Foundation Trust following the receipt of the Regulation 28 report dated 26 February 2024.
The maternity service and wider organisation have taken the concerns raised by the Coroner extremely seriously.
The following actions have been completed or are in progress:
1. Sharing of a ‘message of the week’ within maternity on 4th March 2024 and a global message to all Trust staff on 5th April 2024 regarding the importance of accurate and contemporaneous record keeping, adhering to the Nursing and Midwifery Council (NMC) and General Medical Council (GMC) codes of conduct.
2. Sharing of the message outlined in point 1 at the monthly Trust wide Nursing, Midwifery and Allied Health Professional Quality and Safety meeting on 2nd April 2024, Quality Governance Steering Group on 18th March 2024, Patient and Quality Committee on 26th March 2024, and Trust Board on 28th March 2024.
3. Sharing of the outlined in point 1 at the joint obstetric consultant meeting on 1st March 2024.
4. Action as part of the shift ‘check out’ that the labour ward coordinator checks that all staff have completed their documentation before leaving the shift.
5. An audit of maternity records to assess the quality and prevalence of retrospective entries and record keeping as a whole has been completed. The retrospective notes audit will be an ongoing audit as an addition to the service annual audit plan. The results will be shared within the Quality and safety meetings and newsletters during April and May 2024.
6. Appropriate individual action has been taken with the midwives involved in this case and is ongoing.
Response to the Regulation 28: Report to Prevent Future Deaths following the Inquest touching upon the death of Alissa Norton.
This letter is to outline the actions taken by University Hospitals Sussex NHS Foundation Trust following the receipt of the Regulation 28 report dated 26 February 2024.
The maternity service and wider organisation have taken the concerns raised by the Coroner extremely seriously.
The following actions have been completed or are in progress:
1. Sharing of a ‘message of the week’ within maternity on 4th March 2024 and a global message to all Trust staff on 5th April 2024 regarding the importance of accurate and contemporaneous record keeping, adhering to the Nursing and Midwifery Council (NMC) and General Medical Council (GMC) codes of conduct.
2. Sharing of the message outlined in point 1 at the monthly Trust wide Nursing, Midwifery and Allied Health Professional Quality and Safety meeting on 2nd April 2024, Quality Governance Steering Group on 18th March 2024, Patient and Quality Committee on 26th March 2024, and Trust Board on 28th March 2024.
3. Sharing of the outlined in point 1 at the joint obstetric consultant meeting on 1st March 2024.
4. Action as part of the shift ‘check out’ that the labour ward coordinator checks that all staff have completed their documentation before leaving the shift.
5. An audit of maternity records to assess the quality and prevalence of retrospective entries and record keeping as a whole has been completed. The retrospective notes audit will be an ongoing audit as an addition to the service annual audit plan. The results will be shared within the Quality and safety meetings and newsletters during April and May 2024.
6. Appropriate individual action has been taken with the midwives involved in this case and is ongoing.
Sent To
- University Hospitals Sussex NHS Foundation
Response Status
Linked responses
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56-Day Deadline
22 Apr 2024
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
Report Sections
Investigation and Inquest
On 13 July 2022 I commenced an investigation into the death of Alissa Claire NORTON aged 4 Days. The investigation concluded at the end of the inquest on 22 February 2024. The conclusion of the inquest was that: Alissa Claire Norton died on 22 April 2022 at the Royal Sussex County Hospital, Eastern Road, Brighton from a hypoxic ischaemic encephalopathy caused by chorioamnionitis which she was exposed to prior to her birth on 18 April 2022.
Circumstances of the Death
Alissa Claire Norton died on 22 April 2022 at the Royal Sussex County Hospital, Eastern Road, Brighton from a hypoxic ischaemic encephalopathy caused by chorioamnionitis which she was exposed to prior to her birth on 18 April 2022 at Worthing Hospital, West Sussex.
Copies Sent To
Maternity and Newborn Safety Investigations Special Health Authority (MSNI)
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.