Isabela Suciu
PFD Report
Partially Responded
Ref: 2023-0326
Coroner's Concerns (AI summary)
Conflicting guidelines for newborn hypothermia led to delayed antibiotic administration and create ongoing confusion and risk of missed clinical signs in neonatal units.
View full coroner's concerns
If the Newborn Early Warning Trigger and Track score had been followed the hypothermia would have triggered escalation by the midwife to paediatricians at 02.00 when the temperature was 36.3. Paediatrician
, advised that the KP score would not alter then, but at 06.20, the temperature of 36.2 should have triggered starting antibiotics. There was agreement amongst experts that antibiotics should have been started at 06.20 on 3rd of November. It is accepted by the doctors and Trust that this should have happened and did not because of conflict between the Kaiser Permanente Score and the NICE guidance. Whilst this omission was not shown to have caused Isabela’s death, it creates a possible risk for other hospitals using the KP scale.
Expert microbiologist informed the court that it was not that the KP scale was inferior to NICE recommendations, but rather that there is a risk as the threshold for antibiotics is different, that doctors will think the KP score is gospel and not look at the patient as a whole and therefore miss clinical signs which should trigger starting antibiotics.
, consultant neonatology expert opined that the evidence for the use of KP pathway was thin, and it was better to follow NICE guidance as KP should only be used as part of an overall assessment. Expert neonatologist agreed saying that the use of two guidelines was confusing.
expert opinion was that there was a risk of deaths in other neonatal units and that the expert was not sure how well known the differences and apparent conflict in applying the guidelines was known. The Trust have taken a number of steps to address the risk, but there appears to remain the opportunity for confusion as the revised Newborn Early Warning Trigger and Track score indicates a different response from KP, when late onset symptoms occur after an asymptomatic period, creating a risk of avoidable delay.
6. THE REPORT IS BEING SENT TO:
, Chief Executive of Royal College of Paediatrics and Child Health 5-11, Theobalds Road, London, WC1X 8SH
Chief Executive of the British Association Perinatal Medicine 5-11, Theobalds Road, London, WC1X 8SH
, Chief Executive of NHS England, Skipton House, London, SE1 6LH
, Chief Executive of Queen Elizabeth Hospital Trust Stadium Road, London, SE18 4QH
, advised that the KP score would not alter then, but at 06.20, the temperature of 36.2 should have triggered starting antibiotics. There was agreement amongst experts that antibiotics should have been started at 06.20 on 3rd of November. It is accepted by the doctors and Trust that this should have happened and did not because of conflict between the Kaiser Permanente Score and the NICE guidance. Whilst this omission was not shown to have caused Isabela’s death, it creates a possible risk for other hospitals using the KP scale.
Expert microbiologist informed the court that it was not that the KP scale was inferior to NICE recommendations, but rather that there is a risk as the threshold for antibiotics is different, that doctors will think the KP score is gospel and not look at the patient as a whole and therefore miss clinical signs which should trigger starting antibiotics.
, consultant neonatology expert opined that the evidence for the use of KP pathway was thin, and it was better to follow NICE guidance as KP should only be used as part of an overall assessment. Expert neonatologist agreed saying that the use of two guidelines was confusing.
expert opinion was that there was a risk of deaths in other neonatal units and that the expert was not sure how well known the differences and apparent conflict in applying the guidelines was known. The Trust have taken a number of steps to address the risk, but there appears to remain the opportunity for confusion as the revised Newborn Early Warning Trigger and Track score indicates a different response from KP, when late onset symptoms occur after an asymptomatic period, creating a risk of avoidable delay.
6. THE REPORT IS BEING SENT TO:
, Chief Executive of Royal College of Paediatrics and Child Health 5-11, Theobalds Road, London, WC1X 8SH
Chief Executive of the British Association Perinatal Medicine 5-11, Theobalds Road, London, WC1X 8SH
, Chief Executive of NHS England, Skipton House, London, SE1 6LH
, Chief Executive of Queen Elizabeth Hospital Trust Stadium Road, London, SE18 4QH
Responses
Action Taken
Lewisham and Greenwich NHS Trust provided education sessions on escalating low and high temperatures in neonates, reinforced the Kaiser Permanente pathway, and included Kaiser scoring assessment in neonatal notes. (AI summary)
Lewisham and Greenwich NHS Trust provided education sessions on escalating low and high temperatures in neonates, reinforced the Kaiser Permanente pathway, and included Kaiser scoring assessment in neonatal notes. (AI summary)
View full response
Dear Mr. Harris
Response to Regulation 28 - Prevention of Future Death (PFD) report following inquest into the death of baby Isabela SUCIU. I am writing in response to your report dated 12th August 2023 (assume this should read 12th September 2023 as the date of issue precedes the inquest hearing held on 23 – 24 August
2023). The Trust was alerted of the PFD report on 25 September 2023 via CQC and the court subsequently confirmed notification of the PFD report was erroneously served on another Trust. As such, the Trust is grateful for extension of the response deadline to 20 November
2023. The PFD report highlighted one matter of concern as set out below: o With regards to apparent conflict in applying the Kaiser Permanente Score and NICE guidelines although The Trust have taken a number of steps to address the risk, there appears to remain the opportunity for confusion as the revised Newborn Early Warning Trigger and Track score indicates a different response from Kaiser, when late onset symptoms occur after an asymptomatic period, creating a risk of avoidable delay. We understand the potential for confusion between the revised NEWTT scoring and Kaiser scoring and would like to explain the purpose and scope of both tools and what we have done to mitigate the confusion. Kaiser Permanente is a tool using objective risk factors for sepsis at birth (using maternal information) and the neonatal clinical examination status to give a risk score to guide the management of sepsis. All infants born with risk factors for sepsis (as per NICE CG149 guideline) will have a Kaiser Permanente score to determine the management plan. Prior to the now widely adopted Kaiser Permanente scoring most hospitals used the risks factors in NICE CG149 to determine treatment and antibiotic therapy. However, there were growing concerns of overuse of antibiotics as Early Onset Sepsis only occurs in around 0.7/1000 live births in high income settings, significantly less than the numbers treated for suspected early onset sepsis.
The NEWTT2 scoring chart offers a solution for identifying other babies at risk of deterioration not just babies at risk of sepsis. For example, the NEWTT scoring tool is useful for babies requiring observations for meconium-stained liquor or growth restriction. We are aware that the response on NEWTT2 scoring is different if the baby is treated under the Kaiser Permanente pathway when compared to a baby who is not on the Kaiser pathway and at risk of deterioration for other clinical reasons. With the threshold for intervention being much lower for babies on the Kaiser pathway. Therefore, we do understand that it is important to ensure that it is clear to all staff which pathway the baby is on, as this informs any potential treatment and commencement of antibiotic therapy. Please find set out below details of the actions the Lewisham and Greenwich NHS Trust has already taken to ensure that the difference between the two tools and plans to take in response to the death.
1. Compliance with National Institute for health and Care Excellence (NICE) Guidance for the care of newborn babies The Neonatal service leads have reviewed and updated the following Trust guidelines to be reflective of practice in line with NICE guidance for the care of newborn babies:
• Hypoglycaemia: Management in Neonates Clinical Guideline – updated June 2023
• Kaiser Permanent Score: Early Onset Sepsis Risk Assessment for infants ≥ 34 weeks Guideline - updated December 2022
The Trust has reviewed and is compliant with all recommendations in NICE Guidance (NG) 195: Neonatal Infection; Antibiotics for prevention and treatment.
2. Newborn Early Warning Trigger and Track (NEWTT) Scoring The Trust has updated its paper neonatal notes, which includes the updated NEWTT2 chart, and these were ratified at the Women’s, Sexual Health and Neonates Divisional Governance meeting in October 2023. They were subsequently printed by the Trust Reprographics team and are being implemented with additional teaching and support from practice development midwives throughout both maternity services. All new paper neonatal notes have the Kaiser scoring assessment, pathway and treatment escalation process so that it is clear if a baby is on this pathway. In addition to this we have an assessment tool in the notes which is completed by the midwife or paediatrician following birth to identify which babies are at risk of deterioration, e.g., jaundice, meconium, Kaiser, GBS.
3. Education and Monitoring In addition to the above actions, education sessions were provided for the maternity and transitional care teams to remind staff to always escalate low and high temperatures when performing neonatal observations. The observations for neonates will be prescribed under the Kaiser Permanent pathway, meconium observations pathway or any of the ‘red hat’ pathways and documented in the neonatal notes.
4. Escalation of Hypothermia The Clinical Lead and Senior Matron for Neonatal Services reports that hypothermia is being routinely escalated on the Postnatal Ward. Evidence of this was seen most recently
during the junior doctor’s strikes, when several escalations were made. Most cases of hypothermia reported were attributed to environmental factors which improved when the babies were given skin-to-skin contact or appropriate clothing. However, one escalation resulted in the baby being commenced on intravenous antibiotics and another being admitted to the neonatal unit after their temperature failed to regulate within the expected range which triggered repeated medical reviews. Escalation will continue to be monitored by the Clinical Lead. I would like to assure you that the Trust has taken the concerns raised seriously and learning from this death has been shared at the Divisional ‘Outcomes With Learning’ Group. Should you have any further questions regarding any of the information provided in this letter or require any further information please do not hesitate to contact me.
Response to Regulation 28 - Prevention of Future Death (PFD) report following inquest into the death of baby Isabela SUCIU. I am writing in response to your report dated 12th August 2023 (assume this should read 12th September 2023 as the date of issue precedes the inquest hearing held on 23 – 24 August
2023). The Trust was alerted of the PFD report on 25 September 2023 via CQC and the court subsequently confirmed notification of the PFD report was erroneously served on another Trust. As such, the Trust is grateful for extension of the response deadline to 20 November
2023. The PFD report highlighted one matter of concern as set out below: o With regards to apparent conflict in applying the Kaiser Permanente Score and NICE guidelines although The Trust have taken a number of steps to address the risk, there appears to remain the opportunity for confusion as the revised Newborn Early Warning Trigger and Track score indicates a different response from Kaiser, when late onset symptoms occur after an asymptomatic period, creating a risk of avoidable delay. We understand the potential for confusion between the revised NEWTT scoring and Kaiser scoring and would like to explain the purpose and scope of both tools and what we have done to mitigate the confusion. Kaiser Permanente is a tool using objective risk factors for sepsis at birth (using maternal information) and the neonatal clinical examination status to give a risk score to guide the management of sepsis. All infants born with risk factors for sepsis (as per NICE CG149 guideline) will have a Kaiser Permanente score to determine the management plan. Prior to the now widely adopted Kaiser Permanente scoring most hospitals used the risks factors in NICE CG149 to determine treatment and antibiotic therapy. However, there were growing concerns of overuse of antibiotics as Early Onset Sepsis only occurs in around 0.7/1000 live births in high income settings, significantly less than the numbers treated for suspected early onset sepsis.
The NEWTT2 scoring chart offers a solution for identifying other babies at risk of deterioration not just babies at risk of sepsis. For example, the NEWTT scoring tool is useful for babies requiring observations for meconium-stained liquor or growth restriction. We are aware that the response on NEWTT2 scoring is different if the baby is treated under the Kaiser Permanente pathway when compared to a baby who is not on the Kaiser pathway and at risk of deterioration for other clinical reasons. With the threshold for intervention being much lower for babies on the Kaiser pathway. Therefore, we do understand that it is important to ensure that it is clear to all staff which pathway the baby is on, as this informs any potential treatment and commencement of antibiotic therapy. Please find set out below details of the actions the Lewisham and Greenwich NHS Trust has already taken to ensure that the difference between the two tools and plans to take in response to the death.
1. Compliance with National Institute for health and Care Excellence (NICE) Guidance for the care of newborn babies The Neonatal service leads have reviewed and updated the following Trust guidelines to be reflective of practice in line with NICE guidance for the care of newborn babies:
• Hypoglycaemia: Management in Neonates Clinical Guideline – updated June 2023
• Kaiser Permanent Score: Early Onset Sepsis Risk Assessment for infants ≥ 34 weeks Guideline - updated December 2022
The Trust has reviewed and is compliant with all recommendations in NICE Guidance (NG) 195: Neonatal Infection; Antibiotics for prevention and treatment.
2. Newborn Early Warning Trigger and Track (NEWTT) Scoring The Trust has updated its paper neonatal notes, which includes the updated NEWTT2 chart, and these were ratified at the Women’s, Sexual Health and Neonates Divisional Governance meeting in October 2023. They were subsequently printed by the Trust Reprographics team and are being implemented with additional teaching and support from practice development midwives throughout both maternity services. All new paper neonatal notes have the Kaiser scoring assessment, pathway and treatment escalation process so that it is clear if a baby is on this pathway. In addition to this we have an assessment tool in the notes which is completed by the midwife or paediatrician following birth to identify which babies are at risk of deterioration, e.g., jaundice, meconium, Kaiser, GBS.
3. Education and Monitoring In addition to the above actions, education sessions were provided for the maternity and transitional care teams to remind staff to always escalate low and high temperatures when performing neonatal observations. The observations for neonates will be prescribed under the Kaiser Permanent pathway, meconium observations pathway or any of the ‘red hat’ pathways and documented in the neonatal notes.
4. Escalation of Hypothermia The Clinical Lead and Senior Matron for Neonatal Services reports that hypothermia is being routinely escalated on the Postnatal Ward. Evidence of this was seen most recently
during the junior doctor’s strikes, when several escalations were made. Most cases of hypothermia reported were attributed to environmental factors which improved when the babies were given skin-to-skin contact or appropriate clothing. However, one escalation resulted in the baby being commenced on intravenous antibiotics and another being admitted to the neonatal unit after their temperature failed to regulate within the expected range which triggered repeated medical reviews. Escalation will continue to be monitored by the Clinical Lead. I would like to assure you that the Trust has taken the concerns raised seriously and learning from this death has been shared at the Divisional ‘Outcomes With Learning’ Group. Should you have any further questions regarding any of the information provided in this letter or require any further information please do not hesitate to contact me.
Action Planned
The Royal College of Paediatrics and Child Health will share information and suggestions for local improvement from the report with its paediatric members via its patient safety portal and at the next RCPCH Clinical Quality in Practice committee. (AI summary)
The Royal College of Paediatrics and Child Health will share information and suggestions for local improvement from the report with its paediatric members via its patient safety portal and at the next RCPCH Clinical Quality in Practice committee. (AI summary)
View full response
Dear Mr Harris, Re: RCPCH Response to the Inquest Touching the Death of Isabela Suciu A Regulation 28 Report – Action to Prevent Future Deaths Thank you for sharing a copy of your report with us regarding the tragic and untimely passing of Baby Isabela Suciu. We were saddened to read the circumstances surrounding Isabela’s death and have discussed with senior colleagues within the RCPCH, and our specialty group the British Association of Perinatal Medicine (BAPM). Whilst we are unable to comment on the specifics of case, we do support the view of BAPM who highlight a gap in evidence on whether the Kaiser Permanente Sepsis Risk Calculator or NICE categorical framework is a better tool for determining which babies are most at risk. I have attached BAPM’s response here for completeness. It is critically important that the National Institute for Health and Care Research funds activities seeking to address uncertainties in neonatal care and outcomes. The College will be sharing information and suggestions for local improvement from your report with our paediatric members via its patient safety portal. Your report will also be shared for discussion at the next RCPCH Clinical Quality in Practice committee, where further actions may be identified. Thank you for reminding us of the importance of this work. Our sincere condolences are with Isabela’s family.
Sent To
- NHS England
- Queen Elizabeth Hospital Trust
- Royal College of Paediatrics and Child Health
Response Status
Linked responses
2 of 4
56-Day Deadline
7 Nov 2023
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
The inquest touching the death of Baby Isabela Suciu, was opened on 19 April 2022 and heard on 23rd and 24th August 2023 by the Senior Coroner. The coroner’s reasons for his judgment were handed down and the Record of Inquest was signed on 31st August 2023, recording thus: The medical cause of death was 1a Sudden unexpected neonatal death. Isabela died from a sudden unexpected neonatal death. In the absence of any identifiable cause, such as airway occlusion, research evidence suggests there is often an underlying infection, but although maternal sepsis was a risk factor for neonatal infection, there is insufficient evidence to conclude the underlying cause here.
Circumstances of the Death
Isabela was born in hospital at 41 weeks gestation by forceps, weighing 4.3 kg on 2nd November 2020. She received some resuscitation to achieve an Apgar score of 10 at 5 minutes. Her mother was treated for maternal sepsis and Isabella initially had a temperature of 38. This was monitored and she had two low readings of 36.3 at 02.00 and 36.2 at 06.20. These were not escalated for paediatric review and antibiotics were not given. Her temperature stabilised, and she showed no signs of infection before discharge at 12.51 on 4th December. She suffered a cardiac arrest at home about 35 minutes after a 15 minute breast feed. She never recovered consciousness, despite resuscitation by prompt ambulance officers and she died at 16.10 in hospital.
Copies Sent To
: , Consultant Neonatologist, Northwest Neonatal Ltd , Consultant Neonatologist, Lewisham and Greenwich Trust , Consultant Microbiologist, Lewisham and Greenwich Trust , Consultant Microbiologist, UK Health Security Agency and University College London Hospital NHS Foundation Trust (now retired)
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.