Rachael Walker
PFD Report
All Responded
Ref: 2023-0095Deceased
All 1 response received
· Deadline: 11 May 2023
Coroner's Concerns (AI summary)
The Trust lacks robust and timely processes for updating clinical policies, incorporating national guidance, and obtaining essential equipment, risking similarly avoidable deaths.
View full coroner's concerns
My principal concern is that having heard evidence from the Trust as to ‘lessons learnt’ and its current processes for identifying when Trust clinical policies and guidance needs updating, and where essential equipment needs to be obtained and located, I remain unclear that the Trust now has sufficiently robust processes in place to prevent similarly avoidable deaths to that of Chloe. Indeed, I am unclear that the processes are substantively different to those that existed at the time of Chloe’s death.
It was of very particular concern to hear that clinicians at the time were aware of revised national pregnancy guidance issued in September 2018 but this had not been incorporated into Trust policy and guidance. I was told that introducing revised guidance was necessarily complex and lengthy and yet the Trust did incorporate the revised guidance just several weeks following Chloe’s death and it appears because of her death. It was also very concerning to hear that the Trust had established a regional pregnancy service using out of date guidance. Certain changes relating to the circumstances of Chloe’s death have only very recently been addressed or are in process; for example, the procedure to call and respond to a major maternal haemorrhage was to be tested a week or two after the inquest.
I therefore consider that the Trust should review its processes for identifying when Trust clinical policies and guidance needs updating, and where essential equipment needs to be obtained and located, in the interests of preventing future deaths, and that those processes should ensure timely revisions and associated actions.
It was of very particular concern to hear that clinicians at the time were aware of revised national pregnancy guidance issued in September 2018 but this had not been incorporated into Trust policy and guidance. I was told that introducing revised guidance was necessarily complex and lengthy and yet the Trust did incorporate the revised guidance just several weeks following Chloe’s death and it appears because of her death. It was also very concerning to hear that the Trust had established a regional pregnancy service using out of date guidance. Certain changes relating to the circumstances of Chloe’s death have only very recently been addressed or are in process; for example, the procedure to call and respond to a major maternal haemorrhage was to be tested a week or two after the inquest.
I therefore consider that the Trust should review its processes for identifying when Trust clinical policies and guidance needs updating, and where essential equipment needs to be obtained and located, in the interests of preventing future deaths, and that those processes should ensure timely revisions and associated actions.
Responses
Action Taken
Royal Derby Hospital has taken steps to address concerns around clinical guidelines and equipment, retaining 360 Assurance to audit the measures taken and investing £500k in additional staffing to strengthen leadership and governance in maternity services. The Trust reports to the Perinatal Quality and Safety Group each month. (AI summary)
Royal Derby Hospital has taken steps to address concerns around clinical guidelines and equipment, retaining 360 Assurance to audit the measures taken and investing £500k in additional staffing to strengthen leadership and governance in maternity services. The Trust reports to the Perinatal Quality and Safety Group each month. (AI summary)
View full response
Dear Sir I am writing in response to the Regulation 28 Report dated 16 March 2023, following the Inquest into Mrs Walker's sad death. I firstly want to begin by offering my sincere condolences to Mrs Walker's family and give an assurance that the Trust has taken significant steps to address the concerns that you raised. I note that you have identified two broad areas of concerns relating to governance processes relating to clinical guidelines and equipment. Please find enclosed commentary that I have prepared to given assurance around the actions taken as a result of Mrs Walker's death and following the Prevention of Future Death Report. By way of further assurance, the Trust has retained 360 Assurance to audit the measures taken by the Trust, which will include an audit of the following:
• the structure, roles, responsibilities, attendance and reporting arrangements
• the quality of the minutes and actions including scrutiny and challenge regarding risks, issues and concerns including documentation of these, responsibilities and escalation
• a review of the functioning and effectiveness of the Maternity Services Risk and Governance Strategy
• the effectiveness of the governance across all sites with equal consideration being given to risks, issues and concerns across all sites. The Trust is committed to transforming our maternity services. The Trust's Improvement Action Plan covers the steps we need to take to improve our compliance against Saving Babies’ Lives, Ockenden recommendations, the maternity incentive scheme, locally agreed from actions and recent external reviews of our service. Having everything in one place means we can prioritise, track and measure progress, and clearly hold ourselves to account on when we are going to deliver each action within it. To support this, we will be implementing a project 1
management approach to make sure workstreams are coordinated, and that we use all opportunities to engage with staff and service users. Within the Local Maternity and Neonatal System (LMNS) the Trust reports to the Perinatal Quality and Safety Group (PQSF) each month to ensure accountability for the quality and sustainability of services alongside transformation and improvement activity. The PQSG escalate issues, concerns and risks to the ICS or regional governance structures. Furthermore, the Trust Board has approved and are investing in additional staffing in maternity to the value of £500k to strengthen leadership and governance to support safe care. I hope that this response demonstrates that the Trust are committed to learning from Mrs Walker's death and to improving care for our future patients.
• the structure, roles, responsibilities, attendance and reporting arrangements
• the quality of the minutes and actions including scrutiny and challenge regarding risks, issues and concerns including documentation of these, responsibilities and escalation
• a review of the functioning and effectiveness of the Maternity Services Risk and Governance Strategy
• the effectiveness of the governance across all sites with equal consideration being given to risks, issues and concerns across all sites. The Trust is committed to transforming our maternity services. The Trust's Improvement Action Plan covers the steps we need to take to improve our compliance against Saving Babies’ Lives, Ockenden recommendations, the maternity incentive scheme, locally agreed from actions and recent external reviews of our service. Having everything in one place means we can prioritise, track and measure progress, and clearly hold ourselves to account on when we are going to deliver each action within it. To support this, we will be implementing a project 1
management approach to make sure workstreams are coordinated, and that we use all opportunities to engage with staff and service users. Within the Local Maternity and Neonatal System (LMNS) the Trust reports to the Perinatal Quality and Safety Group (PQSF) each month to ensure accountability for the quality and sustainability of services alongside transformation and improvement activity. The PQSG escalate issues, concerns and risks to the ICS or regional governance structures. Furthermore, the Trust Board has approved and are investing in additional staffing in maternity to the value of £500k to strengthen leadership and governance to support safe care. I hope that this response demonstrates that the Trust are committed to learning from Mrs Walker's death and to improving care for our future patients.
Sent To
- University Hospitals of Derby and Burton NHS FT
Response Status
Linked responses
1 of 1
56-Day Deadline
11 May 2023
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 9 August 2022 I commenced an investigation into the death of Rachael Chloe WALKER aged
36. The investigation concluded at the end of the inquest on 3 March 2023. Article 2 of the European Convention on Human Rights was engaged due to the relevance to Chloe’s death of hospital Trust policies and systems. The conclusion of the inquest was: -
Chloe died of the effects of placental haemorrhage and amniotic fluid embolism at week thirty-seven of her pregnancy due to diagnosed placenta praevia. It is probable that her death would have been avoided if a delivery plan made for her had been recorded in her notes and acted upon, and if the relevant Trust had incorporated national guidance issued in September 2018 which provided for consideration for earlier caesarean delivery.
36. The investigation concluded at the end of the inquest on 3 March 2023. Article 2 of the European Convention on Human Rights was engaged due to the relevance to Chloe’s death of hospital Trust policies and systems. The conclusion of the inquest was: -
Chloe died of the effects of placental haemorrhage and amniotic fluid embolism at week thirty-seven of her pregnancy due to diagnosed placenta praevia. It is probable that her death would have been avoided if a delivery plan made for her had been recorded in her notes and acted upon, and if the relevant Trust had incorporated national guidance issued in September 2018 which provided for consideration for earlier caesarean delivery.
Circumstances of the Death
Rachael Walker, known as Chloe, died in hospital on 19 June 2021 due to experiencing a placental haemorrhage and amniotic fluid embolism at the thirty seventh week of her pregnancy. Chloe had been diagnosed with placenta previa during her antenatal care.
Chloe had antepartum haemorrhage at home on the early morning of 19 June 2021 and had to be taken to hospital by ambulance. At the maternity unit she experienced further haemorrhage and was taken for emergency caesarean section. Her baby was delivered but Chloe quickly went into the first of three cardiac arrests. On the evidence it is not apparent that there was a postpartum haemorrhage, but she did develop blood clotting disorder and disseminated bleeding, likely related to the placental haemorrhage and amniotic fluid embolism. Chloe sadly died in the operating theatre despite prolonged resuscitation attempts.
Chloe had recognised risk factors in her pregnancy and the consultant obstetrician with lead responsibility for her care decided at an appointment at week thirty-four of Chloe’s pregnancy on a plan to review Chloe at an appointment at week thirty-seven, with a view to offering hospital admission and planned caesarean section by week thirty-eight due to the placenta previa. That plan was not recorded in Chloe’s notes with the result that the obstetric registrar who saw Chloe at week thirty-seven was unaware of the plan. Furthermore, the relevant hospital Trust had not adopted national guidance issued in September 2018 for consideration of delivery by caesarean section between weeks thirty-six and thirty-seven in Chloe’s circumstances. Consequently, Chloe was booked for planned caesarean section at week thirty-eight as per Trust guidance. At inquest the Trust accepted these were missed opportunities to avoid Chloe’s death and had they not been missed it is likely that Chloe would not have died because delivery would have occurred well before 19 June, or, if antepartum haemorrhage had occurred during admission, it would have been successfully managed.
Although not clearly causal or contributory to Chloe’s death, I identified the following serious issues from the evidence: -
• The maternity unit did not have a system or proforma to note down and pass on to clinicians information provided by the ambulance service via the dedicated phone line to the unit.
• Blood for urgent use in maternity unit surgery was not kept on or near to the maternity unit.
• There was delay in calling for the on-call consultant anaesthetist to attend once the emergency caesarean section had been called.
• There was no robust system in place for a major obstetric haemorrhage to be called and acted upon with resulting delay in the provision and use of blood products.
• There was insufficient co-ordination and oversight of the emergency team and roles and tasks in the surgical theatre, in particular in oversight of obtaining and use of blood products.
• Certain key equipment was not available for the maternity unit theatre: -
- A blood storage fridge.
- Warming equipment for women during surgery.
- Point of care testing anticoagulation equipment.
Chloe had antepartum haemorrhage at home on the early morning of 19 June 2021 and had to be taken to hospital by ambulance. At the maternity unit she experienced further haemorrhage and was taken for emergency caesarean section. Her baby was delivered but Chloe quickly went into the first of three cardiac arrests. On the evidence it is not apparent that there was a postpartum haemorrhage, but she did develop blood clotting disorder and disseminated bleeding, likely related to the placental haemorrhage and amniotic fluid embolism. Chloe sadly died in the operating theatre despite prolonged resuscitation attempts.
Chloe had recognised risk factors in her pregnancy and the consultant obstetrician with lead responsibility for her care decided at an appointment at week thirty-four of Chloe’s pregnancy on a plan to review Chloe at an appointment at week thirty-seven, with a view to offering hospital admission and planned caesarean section by week thirty-eight due to the placenta previa. That plan was not recorded in Chloe’s notes with the result that the obstetric registrar who saw Chloe at week thirty-seven was unaware of the plan. Furthermore, the relevant hospital Trust had not adopted national guidance issued in September 2018 for consideration of delivery by caesarean section between weeks thirty-six and thirty-seven in Chloe’s circumstances. Consequently, Chloe was booked for planned caesarean section at week thirty-eight as per Trust guidance. At inquest the Trust accepted these were missed opportunities to avoid Chloe’s death and had they not been missed it is likely that Chloe would not have died because delivery would have occurred well before 19 June, or, if antepartum haemorrhage had occurred during admission, it would have been successfully managed.
Although not clearly causal or contributory to Chloe’s death, I identified the following serious issues from the evidence: -
• The maternity unit did not have a system or proforma to note down and pass on to clinicians information provided by the ambulance service via the dedicated phone line to the unit.
• Blood for urgent use in maternity unit surgery was not kept on or near to the maternity unit.
• There was delay in calling for the on-call consultant anaesthetist to attend once the emergency caesarean section had been called.
• There was no robust system in place for a major obstetric haemorrhage to be called and acted upon with resulting delay in the provision and use of blood products.
• There was insufficient co-ordination and oversight of the emergency team and roles and tasks in the surgical theatre, in particular in oversight of obtaining and use of blood products.
• Certain key equipment was not available for the maternity unit theatre: -
- A blood storage fridge.
- Warming equipment for women during surgery.
- Point of care testing anticoagulation equipment.
Copies Sent To
University Hospitals of Derby and Burton NHS FT
East Midlands Ambulance Service
Health Service Investigation Branch (maternal deaths)
Care Quality Commission
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.