Teegan Barnard
PFD Report
All Responded
Ref: 2023-0014Deceased
All 6 responses received
· Deadline: 14 Mar 2023
Coroner's Concerns (AI summary)
Failures included not excluding tension pneumothoraces during cardiac arrest, delayed recognition of surgical emphysema, and the anaesthetic department's failure to investigate or conduct a robust morbidity review after the patient's death.
View full coroner's concerns
1. Resuscitation algorithm (4 H’s & 4 T’s)* for PEA cardiac arrest
I heard evidence that the 4 H’s and 4 T’s should be considered and excluded in any PEA cardiac arrest situation. Steps were taken to treat anaphylaxis, but in the absence of any improvement in Teegan’s clinical condition, and whilst it was mentioned, no steps were taken to exclude possible bilateral tension pneumothoraces. Evidence was heard at the Inquest that it is the only one of the 4 H’s and 4 T’s (see footnote) that directly results in a sudden inability to ventilate, with the HSIB report indicating that there was sufficient time to consider and exclude this possibility given the length of time of the PEA cardiac arrest.
2. Surgical emphysema
There was a delay in the recognition of surgical emphysema by clinical attendees at the cardiac arrest (medical specialist registrar, consultant obstetricians, anaesthetic core trainee, anaesthetic specialist registrar and the on call consultant anaesthetist) despite indicative clinical signs of deep cyanosis, gross whole body swelling with the need to remove the increasingly constrictive hospital wrist band and endotracheal tube tie, alongside sub-cutaneous crepitus and an abdominal drainage bag noted to be tense with air.
3. Investigation after Teegan’s death
Following this incident, and despite Teegan being intubated and ventilated at the time, with a real possibility of this being an anaesthetic related event, no steps were taken by the anaesthetic department at St Richard’s Hospital, Chichester, either before or after the publication of the HSIB report, to explore potential iatrogenic or other anaesthetic related causes (such as exposure of Teegan’s lungs to excessive volume or pressure) as a possible or probable cause of Teegan’s death.
Furthermore, the anaesthetic machine/ventilator was not taken out of service and assessed to see if there was a fault. Neither was the data from the anaesthetic machine downloaded and interrogated, which may have assisted in establishing how Teegan came to develop bilateral tension pneumothoraces during her emergence from general anaesthesia.
The failure of the anaesthetic department to undertake any morbidity or mortality review/meeting following Teegan’s death led to a lost opportunity to share any possible learning opportunities both within and outside their department to prevent future deaths, and as a corollary to have been in a position to fully assist both the investigation by the HSIB and the inquest hearing.
4. Trust Clinical Governance procedures
The senior management team within the Trust have not acknowledged that there was a lack of a proper and robust system in place to trigger an investigation into all the circumstances of the death of a 17-year-old patient, with no steps taken by them to do so either before or after the publication of the HSIB report or at any time prior to the Inquest hearing.
This gives rise to a concern of a lack of insight within the senior management team of the importance of undertaking a comprehensive investigation into unexpected deaths within their organisation and for there to be wider dissemination of any institutional learning with the aim of preventing future deaths.
The failure of the Trust to fully investigate how Teegan came by her death also gives rise to a concern regarding the Trust’s obligation to comply with the Statutory Duty of Candour and their requirement to share their findings with both the regulators and Teegan’s family as well as to indicate the steps, if any, they have taken to prevent future deaths.
*: 4 H’s: Hypothermia, Hypoxia, Hypovolaemia, Hypo/Hyperkalaemia
*: 4 T’s: Tension pneumothorax, Toxins, Thrombosis, Tamponade
I heard evidence that the 4 H’s and 4 T’s should be considered and excluded in any PEA cardiac arrest situation. Steps were taken to treat anaphylaxis, but in the absence of any improvement in Teegan’s clinical condition, and whilst it was mentioned, no steps were taken to exclude possible bilateral tension pneumothoraces. Evidence was heard at the Inquest that it is the only one of the 4 H’s and 4 T’s (see footnote) that directly results in a sudden inability to ventilate, with the HSIB report indicating that there was sufficient time to consider and exclude this possibility given the length of time of the PEA cardiac arrest.
2. Surgical emphysema
There was a delay in the recognition of surgical emphysema by clinical attendees at the cardiac arrest (medical specialist registrar, consultant obstetricians, anaesthetic core trainee, anaesthetic specialist registrar and the on call consultant anaesthetist) despite indicative clinical signs of deep cyanosis, gross whole body swelling with the need to remove the increasingly constrictive hospital wrist band and endotracheal tube tie, alongside sub-cutaneous crepitus and an abdominal drainage bag noted to be tense with air.
3. Investigation after Teegan’s death
Following this incident, and despite Teegan being intubated and ventilated at the time, with a real possibility of this being an anaesthetic related event, no steps were taken by the anaesthetic department at St Richard’s Hospital, Chichester, either before or after the publication of the HSIB report, to explore potential iatrogenic or other anaesthetic related causes (such as exposure of Teegan’s lungs to excessive volume or pressure) as a possible or probable cause of Teegan’s death.
Furthermore, the anaesthetic machine/ventilator was not taken out of service and assessed to see if there was a fault. Neither was the data from the anaesthetic machine downloaded and interrogated, which may have assisted in establishing how Teegan came to develop bilateral tension pneumothoraces during her emergence from general anaesthesia.
The failure of the anaesthetic department to undertake any morbidity or mortality review/meeting following Teegan’s death led to a lost opportunity to share any possible learning opportunities both within and outside their department to prevent future deaths, and as a corollary to have been in a position to fully assist both the investigation by the HSIB and the inquest hearing.
4. Trust Clinical Governance procedures
The senior management team within the Trust have not acknowledged that there was a lack of a proper and robust system in place to trigger an investigation into all the circumstances of the death of a 17-year-old patient, with no steps taken by them to do so either before or after the publication of the HSIB report or at any time prior to the Inquest hearing.
This gives rise to a concern of a lack of insight within the senior management team of the importance of undertaking a comprehensive investigation into unexpected deaths within their organisation and for there to be wider dissemination of any institutional learning with the aim of preventing future deaths.
The failure of the Trust to fully investigate how Teegan came by her death also gives rise to a concern regarding the Trust’s obligation to comply with the Statutory Duty of Candour and their requirement to share their findings with both the regulators and Teegan’s family as well as to indicate the steps, if any, they have taken to prevent future deaths.
*: 4 H’s: Hypothermia, Hypoxia, Hypovolaemia, Hypo/Hyperkalaemia
*: 4 T’s: Tension pneumothorax, Toxins, Thrombosis, Tamponade
Responses
Action Taken
NHS England notes the Trust's strengthened training and improvement work following the death. They highlight ongoing work nationally on maternity services, and dissemination of learning through the Regulation 28 Working Group. (AI summary)
NHS England notes the Trust's strengthened training and improvement work following the death. They highlight ongoing work nationally on maternity services, and dissemination of learning through the Regulation 28 Working Group. (AI summary)
View full response
Dear Coroner,
Re: Regulation 28 Report to Prevent Future Deaths – Teegan Marie Barnard who died on 7th October 2019.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 17th January 2023 concerning the death of Teegan Marie Barnard on 7 October 2019. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Teegan’s family and loved ones. NHS England are keen to assure the family and the coroner that the concerns raised about Teegan’s care have been listened to and reflected upon.
I am also grateful for the further time granted to respond to your Report, and I apologise for any anguish this delay may have caused Teegan’s family or friends. I realise that responses to Coroner Reports can form part of the important process of family and friends coming to terms with what has happened to their loved ones and appreciate this will have been an incredibly difficult time for them.
NHS England have reviewed the response to your Report from University Hospitals Sussex NHS Foundation Trust (hereafter "the Trust") whom we consider are the most appropriate body to respond to the concerns raised. We note that the Trust has identified learning points and strengthened its training for relevant staff members following Teegan’s death as well as the ongoing improvement work to their maternity services, implemented through the Maternity Improvement Programme.
Resuscitation algorithm (4 H’s & 4 T’s)* for PEA cardiac arrest and surgical emphysema
You raised the concern that the resuscitation algorithm of 4 H’s (Hypothermia, Hypoxia, Hypovolaemia, Hypo/Hyperkalaemia) and 4 T’s (Tension pneumothorax, Toxins, Thrombosis, Tamponade) was not applied adequately following Teegan’s cardiac arrest and that there was delay in recognition of surgical emphysema.
The 4 H’s & 4 T’s algorithm is taught as part of the Advance Life Support (ALS) course, a course run by the Resuscitation Council UK and aimed at those healthcare professionals who need skills in ALS as part of their clinical duties, to include doctors, paramedics and nurses working in acute care areas. All anaesthetists, and all doctors National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
11 April 2023
working in any environment where ALS would be required, to include obstetricians and senior members of the cardiac arrest team in this case, are expected to hold an up-to- date ALS certificate (or equivalent) and be across the latest guidance regarding resuscitation and cardiac arrest. Surgical emphysema is covered as part of this course.
Bilateral pneumothoraces occurring as it did in this case is rare and we note that both the Royal College of Anaesthetists (RCoA) and Association of Anaesthetists has stated that most anaesthetists will never encounter such a situation. NHS England’s National Patient Safety Team forms part of the Safe Anaesthesia Liasion Group (SALG), together with the RCoA and the Association of Anaesthetists, who will therefore be sharing the learnings from Teegan’s death across its network of relevant organisations. The national Regulation 28 Working Group will also be asking its regional members to share the learnings with their Integrated Care Boards (ICBs) for onward sharing to Trusts across England.
NHS England also consulted with the Resuscitation Council UK as part of its review of your Report. It should be noted that as a result of Teegan’s death, the Resuscitation Council reviewed the existing ALS guidance and materials, to include consultation of relevant experts. It was concluded that the ALS course did adequately cover the algorithm as well as cardiac arrest in pregnancy.
Trust investigation and Clinical Governance procedures
With regard to the concerns around the subsequent investigation into Teegan’s death, and the fact that there was no local investigation run in parallel to the Healthcare Safety Investigation Branch’s (HSIB’s) investigation, the NHS England National Patient Safety Team has recently launched a new Patient Safety Incident Response Framework (PSIRF), which ‘sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety’.
PSIRF states that “Where [an HSIB maternity] investigation is undertaken, a separate local patient safety learning response is not required. However, organisations should complete Duty of Candour requirements (ahead of handover to HSIB for further involvement of patients/families in the investigation).” We note from the Trust’s response that they have reviewed and strengthened the process for decision-making around the local investigation of incidents when incidents are referred to HSIB. Regarding your concerns around there being no temporary removal of the anaesthetic machine used in this case, or the downloading of information from the machine, we welcome RCoA’s commitment to update its guidance accordingly, to ensure responsibilities around this are made more explicit. We are also aware that the Care Quality Commission (CQC) will be issuing a response to your Report and will review their response and any recommendations made in due course.
I would also like to provide further assurances on national NHSE 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 preventable deaths are shared across the NHS at both a national and regional level and helps us 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.
Re: Regulation 28 Report to Prevent Future Deaths – Teegan Marie Barnard who died on 7th October 2019.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 17th January 2023 concerning the death of Teegan Marie Barnard on 7 October 2019. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Teegan’s family and loved ones. NHS England are keen to assure the family and the coroner that the concerns raised about Teegan’s care have been listened to and reflected upon.
I am also grateful for the further time granted to respond to your Report, and I apologise for any anguish this delay may have caused Teegan’s family or friends. I realise that responses to Coroner Reports can form part of the important process of family and friends coming to terms with what has happened to their loved ones and appreciate this will have been an incredibly difficult time for them.
NHS England have reviewed the response to your Report from University Hospitals Sussex NHS Foundation Trust (hereafter "the Trust") whom we consider are the most appropriate body to respond to the concerns raised. We note that the Trust has identified learning points and strengthened its training for relevant staff members following Teegan’s death as well as the ongoing improvement work to their maternity services, implemented through the Maternity Improvement Programme.
Resuscitation algorithm (4 H’s & 4 T’s)* for PEA cardiac arrest and surgical emphysema
You raised the concern that the resuscitation algorithm of 4 H’s (Hypothermia, Hypoxia, Hypovolaemia, Hypo/Hyperkalaemia) and 4 T’s (Tension pneumothorax, Toxins, Thrombosis, Tamponade) was not applied adequately following Teegan’s cardiac arrest and that there was delay in recognition of surgical emphysema.
The 4 H’s & 4 T’s algorithm is taught as part of the Advance Life Support (ALS) course, a course run by the Resuscitation Council UK and aimed at those healthcare professionals who need skills in ALS as part of their clinical duties, to include doctors, paramedics and nurses working in acute care areas. All anaesthetists, and all doctors National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
11 April 2023
working in any environment where ALS would be required, to include obstetricians and senior members of the cardiac arrest team in this case, are expected to hold an up-to- date ALS certificate (or equivalent) and be across the latest guidance regarding resuscitation and cardiac arrest. Surgical emphysema is covered as part of this course.
Bilateral pneumothoraces occurring as it did in this case is rare and we note that both the Royal College of Anaesthetists (RCoA) and Association of Anaesthetists has stated that most anaesthetists will never encounter such a situation. NHS England’s National Patient Safety Team forms part of the Safe Anaesthesia Liasion Group (SALG), together with the RCoA and the Association of Anaesthetists, who will therefore be sharing the learnings from Teegan’s death across its network of relevant organisations. The national Regulation 28 Working Group will also be asking its regional members to share the learnings with their Integrated Care Boards (ICBs) for onward sharing to Trusts across England.
NHS England also consulted with the Resuscitation Council UK as part of its review of your Report. It should be noted that as a result of Teegan’s death, the Resuscitation Council reviewed the existing ALS guidance and materials, to include consultation of relevant experts. It was concluded that the ALS course did adequately cover the algorithm as well as cardiac arrest in pregnancy.
Trust investigation and Clinical Governance procedures
With regard to the concerns around the subsequent investigation into Teegan’s death, and the fact that there was no local investigation run in parallel to the Healthcare Safety Investigation Branch’s (HSIB’s) investigation, the NHS England National Patient Safety Team has recently launched a new Patient Safety Incident Response Framework (PSIRF), which ‘sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety’.
PSIRF states that “Where [an HSIB maternity] investigation is undertaken, a separate local patient safety learning response is not required. However, organisations should complete Duty of Candour requirements (ahead of handover to HSIB for further involvement of patients/families in the investigation).” We note from the Trust’s response that they have reviewed and strengthened the process for decision-making around the local investigation of incidents when incidents are referred to HSIB. Regarding your concerns around there being no temporary removal of the anaesthetic machine used in this case, or the downloading of information from the machine, we welcome RCoA’s commitment to update its guidance accordingly, to ensure responsibilities around this are made more explicit. We are also aware that the Care Quality Commission (CQC) will be issuing a response to your Report and will review their response and any recommendations made in due course.
I would also like to provide further assurances on national NHSE 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 preventable deaths are shared across the NHS at both a national and regional level and helps us 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.
Action Planned
The Royal College of Anaesthetists will share learning about bilateral pneumothoraces as a cause of cardiac arrest via its Patient Safety Update. They will also amend guidance to ensure responsibilities around investigation and equipment management after catastrophic events are clear and embed this change into practice through the RCoA’s Anaesthesia Clinical Services Accreditation scheme. (AI summary)
The Royal College of Anaesthetists will share learning about bilateral pneumothoraces as a cause of cardiac arrest via its Patient Safety Update. They will also amend guidance to ensure responsibilities around investigation and equipment management after catastrophic events are clear and embed this change into practice through the RCoA’s Anaesthesia Clinical Services Accreditation scheme. (AI summary)
View full response
Dear Dr Henderson,
Re: Regulation 28: Report to Prevent Future Deaths in the matter of Teegan Marie Barnard
Thank you for sending us a copy of your Regulation 28 Report regarding the sad death of Teegan Marie Barnard. We have jointly reviewed the information available to us in the report via our Safe Anaesthesia Liaison Group (SALG). SALG is a collaborative project between the Association of Anaesthetists, NHS England’s Patient Safety team and the Royal College of Anaesthetists. One of its core objectives is to analyse anaesthesia-related serious incidents and to share the learning with the specialty across the UK.
Bilateral pneumothoraces occurring on emergence from a general anaesthetic, especially one for surgery that did not include thoracotomy or thorascopy, is so rare that most anaesthetists will never encounter such a situation. All anaesthetists are taught the 8 reversible causes of cardiac arrest through the Resuscitation Council’s Advanced Life Support course, or an equivalent, that they must complete as part of their training and maintain their competencies throughout their career. Bilateral pneumothoraces are mentioned only in the setting of trauma in the Resuscitation Council’s guidelines. For this reason, we will share the learning from Teegan’s death that bilateral pneumothoraces can be cause of failure to ventilate leading to cardiac arrest in the absence of trauma or thoracic surgery. We will do so via SALG’s Patient Safety Update, which is shared with all members of our respective organisations, and via our education and events.
There are mechanisms to support staff to respond to challenging clinical emergencies, such as that described in your report. All organisations should have a clear system for calling for additional clinical support in emergency situations and it is clear from your report that this was in place at St Richards Hospital, Chichester. Cognitive aids, such as that produced by the Association of Anaesthetists1 can be helpful during a crisis when the cognitive load can impair performance. They are only effective, however, if the organisation has ensured that all staff are given the time to become practised in their use. In the recent Association of Anaesthetists and Difficult Airway Society publication on human factors in anaesthetic practice2 and in Royal College guidelines3, we recommend that this is done through multidisciplinary team training, so that the team that works together can learn together how to respond to unexpected or uncommon emergencies.
Your report highlights the importance of reporting, investigating and sharing learning from critical incidents. The Royal College guidelines3 outline in detail the systems that departments should have in place to respond to critical incidents, emphasising both the need to investigate and embed the learning from such incidents and the importance of supporting patients, patients’ family and the staff involved.
A systems-based approach to learning from patient safety incidents is acknowledged as the most effective way to understand how incidents happen and the factors that contribute to them, as included in both our guidance and the recently published NHS England Patient Safety Incident Response Framework. Both our guidance and the new framework also focus on the compassionate engagement of those affected by the incident, including staff members who
may be affected by the “second victim” phenomenon and be severely emotionally affected by this. Organisations should have formal, sympathetic and structured support available for all those affected by patient safety incidents. Patient safety incidents can be subject to multiple investigations from both within the organisation and by external bodies. Consideration should be given to how these are coordinated in order to reduce the duplication of effort, to ensure that the learning for the system as a whole can be embedded into practice as soon as feasible and to prevent compounded harm to those involved during the investigations.4
We have reviewed our guidance in light of your report and we have recognised that we should be more explicit about the need for a standardised process of investigation which is automatically triggered immediately after a catastrophic event. This should ensure that responsibility for steps such as downloading information from the anaesthetic machine or the temporary removal of equipment from service for checking, is removed from those directly involved. We will amend our guidance accordingly, promote these changes to the specialty and embed this change into practice through the RCoA’s Anaesthesia Clinical Services Accreditation scheme. We also note that the implementation of our recommendation that all departments should have an appropriate electronic anaesthetic record system, linked to the wider electronic patient record, would aid the investigation of incidents.
We would be happy to respond to any questions that you might have.
Re: Regulation 28: Report to Prevent Future Deaths in the matter of Teegan Marie Barnard
Thank you for sending us a copy of your Regulation 28 Report regarding the sad death of Teegan Marie Barnard. We have jointly reviewed the information available to us in the report via our Safe Anaesthesia Liaison Group (SALG). SALG is a collaborative project between the Association of Anaesthetists, NHS England’s Patient Safety team and the Royal College of Anaesthetists. One of its core objectives is to analyse anaesthesia-related serious incidents and to share the learning with the specialty across the UK.
Bilateral pneumothoraces occurring on emergence from a general anaesthetic, especially one for surgery that did not include thoracotomy or thorascopy, is so rare that most anaesthetists will never encounter such a situation. All anaesthetists are taught the 8 reversible causes of cardiac arrest through the Resuscitation Council’s Advanced Life Support course, or an equivalent, that they must complete as part of their training and maintain their competencies throughout their career. Bilateral pneumothoraces are mentioned only in the setting of trauma in the Resuscitation Council’s guidelines. For this reason, we will share the learning from Teegan’s death that bilateral pneumothoraces can be cause of failure to ventilate leading to cardiac arrest in the absence of trauma or thoracic surgery. We will do so via SALG’s Patient Safety Update, which is shared with all members of our respective organisations, and via our education and events.
There are mechanisms to support staff to respond to challenging clinical emergencies, such as that described in your report. All organisations should have a clear system for calling for additional clinical support in emergency situations and it is clear from your report that this was in place at St Richards Hospital, Chichester. Cognitive aids, such as that produced by the Association of Anaesthetists1 can be helpful during a crisis when the cognitive load can impair performance. They are only effective, however, if the organisation has ensured that all staff are given the time to become practised in their use. In the recent Association of Anaesthetists and Difficult Airway Society publication on human factors in anaesthetic practice2 and in Royal College guidelines3, we recommend that this is done through multidisciplinary team training, so that the team that works together can learn together how to respond to unexpected or uncommon emergencies.
Your report highlights the importance of reporting, investigating and sharing learning from critical incidents. The Royal College guidelines3 outline in detail the systems that departments should have in place to respond to critical incidents, emphasising both the need to investigate and embed the learning from such incidents and the importance of supporting patients, patients’ family and the staff involved.
A systems-based approach to learning from patient safety incidents is acknowledged as the most effective way to understand how incidents happen and the factors that contribute to them, as included in both our guidance and the recently published NHS England Patient Safety Incident Response Framework. Both our guidance and the new framework also focus on the compassionate engagement of those affected by the incident, including staff members who
may be affected by the “second victim” phenomenon and be severely emotionally affected by this. Organisations should have formal, sympathetic and structured support available for all those affected by patient safety incidents. Patient safety incidents can be subject to multiple investigations from both within the organisation and by external bodies. Consideration should be given to how these are coordinated in order to reduce the duplication of effort, to ensure that the learning for the system as a whole can be embedded into practice as soon as feasible and to prevent compounded harm to those involved during the investigations.4
We have reviewed our guidance in light of your report and we have recognised that we should be more explicit about the need for a standardised process of investigation which is automatically triggered immediately after a catastrophic event. This should ensure that responsibility for steps such as downloading information from the anaesthetic machine or the temporary removal of equipment from service for checking, is removed from those directly involved. We will amend our guidance accordingly, promote these changes to the specialty and embed this change into practice through the RCoA’s Anaesthesia Clinical Services Accreditation scheme. We also note that the implementation of our recommendation that all departments should have an appropriate electronic anaesthetic record system, linked to the wider electronic patient record, would aid the investigation of incidents.
We would be happy to respond to any questions that you might have.
Action Planned
The Royal College of Anaesthetists will share learning about bilateral pneumothoraces as a cause of cardiac arrest via its Patient Safety Update. They will also amend guidance to ensure responsibilities around investigation and equipment management after catastrophic events are clear and embed this change into practice through the RCoA’s Anaesthesia Clinical Services Accreditation scheme. (AI summary)
The Royal College of Anaesthetists will share learning about bilateral pneumothoraces as a cause of cardiac arrest via its Patient Safety Update. They will also amend guidance to ensure responsibilities around investigation and equipment management after catastrophic events are clear and embed this change into practice through the RCoA’s Anaesthesia Clinical Services Accreditation scheme. (AI summary)
View full response
Dear Dr Henderson,
Re: Regulation 28: Report to Prevent Future Deaths in the matter of Teegan Marie Barnard
Thank you for sending us a copy of your Regulation 28 Report regarding the sad death of Teegan Marie Barnard. We have jointly reviewed the information available to us in the report via our Safe Anaesthesia Liaison Group (SALG). SALG is a collaborative project between the Association of Anaesthetists, NHS England’s Patient Safety team and the Royal College of Anaesthetists. One of its core objectives is to analyse anaesthesia-related serious incidents and to share the learning with the specialty across the UK.
Bilateral pneumothoraces occurring on emergence from a general anaesthetic, especially one for surgery that did not include thoracotomy or thorascopy, is so rare that most anaesthetists will never encounter such a situation. All anaesthetists are taught the 8 reversible causes of cardiac arrest through the Resuscitation Council’s Advanced Life Support course, or an equivalent, that they must complete as part of their training and maintain their competencies throughout their career. Bilateral pneumothoraces are mentioned only in the setting of trauma in the Resuscitation Council’s guidelines. For this reason, we will share the learning from Teegan’s death that bilateral pneumothoraces can be cause of failure to ventilate leading to cardiac arrest in the absence of trauma or thoracic surgery. We will do so via SALG’s Patient Safety Update, which is shared with all members of our respective organisations, and via our education and events.
There are mechanisms to support staff to respond to challenging clinical emergencies, such as that described in your report. All organisations should have a clear system for calling for additional clinical support in emergency situations and it is clear from your report that this was in place at St Richards Hospital, Chichester. Cognitive aids, such as that produced by the Association of Anaesthetists1 can be helpful during a crisis when the cognitive load can impair performance. They are only effective, however, if the organisation has ensured that all staff are given the time to become practised in their use. In the recent Association of Anaesthetists and Difficult Airway Society publication on human factors in anaesthetic practice2 and in Royal College guidelines3, we recommend that this is done through multidisciplinary team training, so that the team that works together can learn together how to respond to unexpected or uncommon emergencies.
Your report highlights the importance of reporting, investigating and sharing learning from critical incidents. The Royal College guidelines3 outline in detail the systems that departments should have in place to respond to critical incidents, emphasising both the need to investigate and embed the learning from such incidents and the importance of supporting patients, patients’ family and the staff involved.
A systems-based approach to learning from patient safety incidents is acknowledged as the most effective way to understand how incidents happen and the factors that contribute to them, as included in both our guidance and the recently published NHS England Patient Safety Incident Response Framework. Both our guidance and the new framework also focus on the compassionate engagement of those affected by the incident, including staff members who
may be affected by the “second victim” phenomenon and be severely emotionally affected by this. Organisations should have formal, sympathetic and structured support available for all those affected by patient safety incidents. Patient safety incidents can be subject to multiple investigations from both within the organisation and by external bodies. Consideration should be given to how these are coordinated in order to reduce the duplication of effort, to ensure that the learning for the system as a whole can be embedded into practice as soon as feasible and to prevent compounded harm to those involved during the investigations.4
We have reviewed our guidance in light of your report and we have recognised that we should be more explicit about the need for a standardised process of investigation which is automatically triggered immediately after a catastrophic event. This should ensure that responsibility for steps such as downloading information from the anaesthetic machine or the temporary removal of equipment from service for checking, is removed from those directly involved. We will amend our guidance accordingly, promote these changes to the specialty and embed this change into practice through the RCoA’s Anaesthesia Clinical Services Accreditation scheme. We also note that the implementation of our recommendation that all departments should have an appropriate electronic anaesthetic record system, linked to the wider electronic patient record, would aid the investigation of incidents.
We would be happy to respond to any questions that you might have.
Re: Regulation 28: Report to Prevent Future Deaths in the matter of Teegan Marie Barnard
Thank you for sending us a copy of your Regulation 28 Report regarding the sad death of Teegan Marie Barnard. We have jointly reviewed the information available to us in the report via our Safe Anaesthesia Liaison Group (SALG). SALG is a collaborative project between the Association of Anaesthetists, NHS England’s Patient Safety team and the Royal College of Anaesthetists. One of its core objectives is to analyse anaesthesia-related serious incidents and to share the learning with the specialty across the UK.
Bilateral pneumothoraces occurring on emergence from a general anaesthetic, especially one for surgery that did not include thoracotomy or thorascopy, is so rare that most anaesthetists will never encounter such a situation. All anaesthetists are taught the 8 reversible causes of cardiac arrest through the Resuscitation Council’s Advanced Life Support course, or an equivalent, that they must complete as part of their training and maintain their competencies throughout their career. Bilateral pneumothoraces are mentioned only in the setting of trauma in the Resuscitation Council’s guidelines. For this reason, we will share the learning from Teegan’s death that bilateral pneumothoraces can be cause of failure to ventilate leading to cardiac arrest in the absence of trauma or thoracic surgery. We will do so via SALG’s Patient Safety Update, which is shared with all members of our respective organisations, and via our education and events.
There are mechanisms to support staff to respond to challenging clinical emergencies, such as that described in your report. All organisations should have a clear system for calling for additional clinical support in emergency situations and it is clear from your report that this was in place at St Richards Hospital, Chichester. Cognitive aids, such as that produced by the Association of Anaesthetists1 can be helpful during a crisis when the cognitive load can impair performance. They are only effective, however, if the organisation has ensured that all staff are given the time to become practised in their use. In the recent Association of Anaesthetists and Difficult Airway Society publication on human factors in anaesthetic practice2 and in Royal College guidelines3, we recommend that this is done through multidisciplinary team training, so that the team that works together can learn together how to respond to unexpected or uncommon emergencies.
Your report highlights the importance of reporting, investigating and sharing learning from critical incidents. The Royal College guidelines3 outline in detail the systems that departments should have in place to respond to critical incidents, emphasising both the need to investigate and embed the learning from such incidents and the importance of supporting patients, patients’ family and the staff involved.
A systems-based approach to learning from patient safety incidents is acknowledged as the most effective way to understand how incidents happen and the factors that contribute to them, as included in both our guidance and the recently published NHS England Patient Safety Incident Response Framework. Both our guidance and the new framework also focus on the compassionate engagement of those affected by the incident, including staff members who
may be affected by the “second victim” phenomenon and be severely emotionally affected by this. Organisations should have formal, sympathetic and structured support available for all those affected by patient safety incidents. Patient safety incidents can be subject to multiple investigations from both within the organisation and by external bodies. Consideration should be given to how these are coordinated in order to reduce the duplication of effort, to ensure that the learning for the system as a whole can be embedded into practice as soon as feasible and to prevent compounded harm to those involved during the investigations.4
We have reviewed our guidance in light of your report and we have recognised that we should be more explicit about the need for a standardised process of investigation which is automatically triggered immediately after a catastrophic event. This should ensure that responsibility for steps such as downloading information from the anaesthetic machine or the temporary removal of equipment from service for checking, is removed from those directly involved. We will amend our guidance accordingly, promote these changes to the specialty and embed this change into practice through the RCoA’s Anaesthesia Clinical Services Accreditation scheme. We also note that the implementation of our recommendation that all departments should have an appropriate electronic anaesthetic record system, linked to the wider electronic patient record, would aid the investigation of incidents.
We would be happy to respond to any questions that you might have.
Action Planned
The CQC has requested information from University Hospitals Sussex NHS Foundation Trust regarding actions taken and intended in response to the report. They will monitor the Trust's progress and compliance, including implementation of the national medical examiner system and processes for equipment isolation. (AI summary)
The CQC has requested information from University Hospitals Sussex NHS Foundation Trust regarding actions taken and intended in response to the report. They will monitor the Trust's progress and compliance, including implementation of the national medical examiner system and processes for equipment isolation. (AI summary)
View full response
Dear HM Coroner Prevention of future death report following inquest into the death of Teegan Marie Barnard Thank you for sending CQC a copy of the prevention of future death report issued following the death of Teegan Marie Barnard. CQC has contacted the provider University Hospitals Sussex NHS Foundation Trust to request written confirmation and evidence of the action they have taken to date following this death and any additional action they intend to take in response to the prevention of future death report. We note the legal requirement upon the following individuals and organisations to respond to your report within 56 days: 1 , Chief Executive U. Hospitals Sussex NHS Foundation Trust 2 , Medical Director, St Richards Hospital, Chichester 3 Chief Executive NHS England 4 Chief Executive Health Education England 5 Chief Executive CQC We are responding as directed. Having received your report, the CQC took steps to request information and seek assurance from the Trust regarding the concerns within the report. University Sussex
Hospital NHS Trust have provided the following documents which CQC have reviewed:
1. Maternity Improvement Plan - 23.1.23 incl Ockenden (DRAFT)
2. CNST MIS_SafetyAction_2023_V9_UHSussex 31012023
3. Local Requirements for HSIB Investigations Standard Operating Procedure 3 Safety Action 8 compliance with multi-professional training
4. Integrated UHS Learning from Deaths Annual Report 4 Summary Hospital - level Mortality Indicator (SHMI) report January 2022- December 2022. 5 Quality Mortality Earlier Intervention report 6 Letter from trust dated 16 February 2023 outlining action taken prevention of future death report. We have also reviewed the following documents:
1.) Summing up and conclusion from HM Coroner
2.) Reg 28 Coroner evidence BARNARD - 6. Full Inquest Additional 1
3.) Reg 28 Evidence from Coroner BARNARD - 3. Full Inquest Exhibits Medical Records.
4.) Regulation 28 report.
5.) Reg 28 Evidence form Coroner BARNARD - 1. Full Inquest Statements Over the last 18 months, CQC have discharged its regulatory function through enhanced monitoring, engagement and inspection of maternity services at each main hospital site. For ease we will set out all the inspections undertaken in the last 13 months. Royal Sussex County Hospital, Brighton 28 September - 04 October 2021 o Maternity rated inadequate Link to report: https://api.cqc.org.uk/public/v1/reports/65b10d86-462c-4f8d-b6de 907e7356cf15?20211223171918 26 and 27 April 2022 (follow up inspection to check compliance against warning notice issued following above inspection) o Maternity – inspected but not rated Link to report : https://api.cqc.org.uk/public/v1/reports/c55b73a3-3d17-4e31-833e 59556e80cc95?20220729070335 Princess Royal Hospital, Haywards Heath 28 September – 04 October 2021 o Maternity rated inadequate Link to report: https://api.cqc.org.uk/public/v1/reports/300ee9ab-0ee2-4035-aa37 0d5b851b47cc?20211223171918 26 and 27 April 2022 o Maternity – inspected but not rated (follow up inspection to check compliance against warning notice issued following above inspection) Link to report: https://api.cqc.org.uk/public/v1/reports/d5a15938-fa30-45b4-bb35 2eeab72fc3b2?20220729070335
St Richards Hospital, Chichester 28 September – 4 October 2021 o Maternity rated requires improvement. Link to report: https://api.cqc.org.uk/public/v1/reports/19c41cd3-3d04-4476-b809- a23a81d695c0?20211223171918 26 - 27 April 2022 o Maternity – inspected but not rated inspected but not rated (follow up inspection to check compliance against warning notice issued following above inspection) Link to report: https://api.cqc.org.uk/public/v1/reports/81170a7a-3725-4a88-a459 6eef3de0b385?20220729070335 Worthing Hospital 28 September – 04 October 2021 o Maternity rated requires improvement. Link to report: https://api.cqc.org.uk/public/v1/reports/9a45b0c0-8332-4635-8bb0 5e66defae1a6?20211223171918 26 and 27 April 2022 o Maternity – inspected but not rated (follow up inspection to check compliance against warning notice issued following above inspection) Link to report: https://api.cqc.org.uk/public/v1/reports/e8ede713-1a80-40e0-8687 37b3344c4522?20220729070335 A Trust wide Well Led inspection was undertaken on 4 and 5 October 2022.The report is still undergoing quality assurances processes and will be published on our website in due course. CQC note the concerns outlined in section 5 of the Regulation 28 report. Action CQC intends to take is to agree with the Trust regular engagement meetings to monitor and have oversight of the following:
1.) Request and monitor staff training compliance with emergency life support training and the management of deteriorating patients.
2.) Review audits undertaken by University Sussex Hospital NHS Trust in the management of deteriorating patients and compliance against the Trust’s policies.
3.) Completion of actions from HSIB reports.
4.) Progress against actions outlined in the Maternity Safety Support Program.
5.) Monitor progress against Trust’s action plans in response to CQC inspections.
6.) Monitor Summary Hospital-level Mortality Indicators for the Trust. The time frame for completion is within the next three months to establish agreed frequency to meet with the Trust. Additional actions CQC propose to take (for completion within the same timescale) are:
1.) Monitor the Trust’s progress and compliance in implementing the national medical examiner system by April 2023.
2.) Seek confirmation that the Trust have an established process for the isolation of any medical equipment involved when an event happens when equipment may be involved.
3.) Information sharing and collaborative working with HSIB.
4.) CQC will request information from the Trust which demonstrates compliance with Regulation 20: Duty of Candour. If CQC deems insufficient progress has been made by the Trust or if there is risk to service users, CQC will consider discharging its regulatory functions. Should you require further information from CQC, please contact us.
Thank you in advance for your assistance.
Hospital NHS Trust have provided the following documents which CQC have reviewed:
1. Maternity Improvement Plan - 23.1.23 incl Ockenden (DRAFT)
2. CNST MIS_SafetyAction_2023_V9_UHSussex 31012023
3. Local Requirements for HSIB Investigations Standard Operating Procedure 3 Safety Action 8 compliance with multi-professional training
4. Integrated UHS Learning from Deaths Annual Report 4 Summary Hospital - level Mortality Indicator (SHMI) report January 2022- December 2022. 5 Quality Mortality Earlier Intervention report 6 Letter from trust dated 16 February 2023 outlining action taken prevention of future death report. We have also reviewed the following documents:
1.) Summing up and conclusion from HM Coroner
2.) Reg 28 Coroner evidence BARNARD - 6. Full Inquest Additional 1
3.) Reg 28 Evidence from Coroner BARNARD - 3. Full Inquest Exhibits Medical Records.
4.) Regulation 28 report.
5.) Reg 28 Evidence form Coroner BARNARD - 1. Full Inquest Statements Over the last 18 months, CQC have discharged its regulatory function through enhanced monitoring, engagement and inspection of maternity services at each main hospital site. For ease we will set out all the inspections undertaken in the last 13 months. Royal Sussex County Hospital, Brighton 28 September - 04 October 2021 o Maternity rated inadequate Link to report: https://api.cqc.org.uk/public/v1/reports/65b10d86-462c-4f8d-b6de 907e7356cf15?20211223171918 26 and 27 April 2022 (follow up inspection to check compliance against warning notice issued following above inspection) o Maternity – inspected but not rated Link to report : https://api.cqc.org.uk/public/v1/reports/c55b73a3-3d17-4e31-833e 59556e80cc95?20220729070335 Princess Royal Hospital, Haywards Heath 28 September – 04 October 2021 o Maternity rated inadequate Link to report: https://api.cqc.org.uk/public/v1/reports/300ee9ab-0ee2-4035-aa37 0d5b851b47cc?20211223171918 26 and 27 April 2022 o Maternity – inspected but not rated (follow up inspection to check compliance against warning notice issued following above inspection) Link to report: https://api.cqc.org.uk/public/v1/reports/d5a15938-fa30-45b4-bb35 2eeab72fc3b2?20220729070335
St Richards Hospital, Chichester 28 September – 4 October 2021 o Maternity rated requires improvement. Link to report: https://api.cqc.org.uk/public/v1/reports/19c41cd3-3d04-4476-b809- a23a81d695c0?20211223171918 26 - 27 April 2022 o Maternity – inspected but not rated inspected but not rated (follow up inspection to check compliance against warning notice issued following above inspection) Link to report: https://api.cqc.org.uk/public/v1/reports/81170a7a-3725-4a88-a459 6eef3de0b385?20220729070335 Worthing Hospital 28 September – 04 October 2021 o Maternity rated requires improvement. Link to report: https://api.cqc.org.uk/public/v1/reports/9a45b0c0-8332-4635-8bb0 5e66defae1a6?20211223171918 26 and 27 April 2022 o Maternity – inspected but not rated (follow up inspection to check compliance against warning notice issued following above inspection) Link to report: https://api.cqc.org.uk/public/v1/reports/e8ede713-1a80-40e0-8687 37b3344c4522?20220729070335 A Trust wide Well Led inspection was undertaken on 4 and 5 October 2022.The report is still undergoing quality assurances processes and will be published on our website in due course. CQC note the concerns outlined in section 5 of the Regulation 28 report. Action CQC intends to take is to agree with the Trust regular engagement meetings to monitor and have oversight of the following:
1.) Request and monitor staff training compliance with emergency life support training and the management of deteriorating patients.
2.) Review audits undertaken by University Sussex Hospital NHS Trust in the management of deteriorating patients and compliance against the Trust’s policies.
3.) Completion of actions from HSIB reports.
4.) Progress against actions outlined in the Maternity Safety Support Program.
5.) Monitor progress against Trust’s action plans in response to CQC inspections.
6.) Monitor Summary Hospital-level Mortality Indicators for the Trust. The time frame for completion is within the next three months to establish agreed frequency to meet with the Trust. Additional actions CQC propose to take (for completion within the same timescale) are:
1.) Monitor the Trust’s progress and compliance in implementing the national medical examiner system by April 2023.
2.) Seek confirmation that the Trust have an established process for the isolation of any medical equipment involved when an event happens when equipment may be involved.
3.) Information sharing and collaborative working with HSIB.
4.) CQC will request information from the Trust which demonstrates compliance with Regulation 20: Duty of Candour. If CQC deems insufficient progress has been made by the Trust or if there is risk to service users, CQC will consider discharging its regulatory functions. Should you require further information from CQC, please contact us.
Thank you in advance for your assistance.
Action Taken
St Richard's Hospital describes their Maternity Improvement Program developed with the Maternity Safety Support Program and the achievement of year 4 requirements of the Clinical Negligence Scheme for Trusts (CNST). They have also reviewed and strengthened processes for decision making about the local investigation of incidents referred to HSIB. (AI summary)
St Richard's Hospital describes their Maternity Improvement Program developed with the Maternity Safety Support Program and the achievement of year 4 requirements of the Clinical Negligence Scheme for Trusts (CNST). They have also reviewed and strengthened processes for decision making about the local investigation of incidents referred to HSIB. (AI summary)
View full response
Dear Dr Henderson, RE: Regulation 28 Report to Prevent Future Deaths – Teegan BARNARD I am writing in response to the Regulation 28 Report issued following the Inquest into the death of Teegan Marie Barnard. Following Teegan’s death there has been intense focus to ensure that our maternity services are of the highest quality and are safe, and this is ongoing. Following the CQC visit to our maternity services in 2021 we have worked with the Maternity Safety Support Program (MSSP) and developed our Maternity Improvement Program (MIP) with their support. We have also worked hard to achieve the requirements of year 4 of the Clinical Negligence Scheme for Trusts (CNST). The Trust achieved 154 of the 155 requirements for our submission which is a huge achievement and is indicative of our focus on the safety of our maternity services. Our evidence was rigorously assessed by the internal auditors (BDO) and reviewed by the Local Maternity and Neonatal system governance lead and ICB panel. The Trust is also confident that the staff involved worked to the best of their abilities during this tragic event. In the Regulation 28 Report concerns are raised about the following issues.
1. The resuscitation algorithm (4H’s and 4T’s) for PEA arrest
2. Surgical emphysema
3. The Investigation following Teegan’s death.
4. Trust Clinical Governance procedures.
Our responses are outlined below but also address matters of factual accuracy.
(1) The resuscitation algorithm and (2) surgical emphysema You have raised concerns that although there are 8 contributory causes of Pulseless Electrical Activity (PEA) cardiac arrest (the 4H’s and 4 T’s), only one of these, tension pneumothorax, also causes a sudden inability to ventilate a patient; it was therefore determined that there was a delay in the team identifying this as the cause of the PEA arrest. Concern has also been raised that there was a delay in the team identifying surgical emphysema despite the presence of indicative signs. The Trust has been copied into the PFD response from the Royal College of Anaesthetists and UK Anaesthetic Association and note their comment that Bilateral pneumothoraces occurring on emergence from a general anaesthetic, especially one for surgery that did not include thoracotomy or thoracoscopy, is so rare that most anaesthetists will never encounter such a situation. However, the Trust recognises that for staff to perform optimally in extremely challenging situations such as maternal cardiac arrest appropriate training is essential. The Trust has therefore taken action to ensure all the appropriate members of the Multi-Disciplinary Team (MDT) have received the necessary training to be able to manage obstetric emergencies. An audit conducted in January 2023 demonstrates that over 90% of the obstetric, anaesthetic and midwifery staff that work within the labour ward environment across the entire organisation had received this MDT training. This reaches the stringent standards set for training by the Clinical Negligence Scheme for Trusts year 4 requirements. Of note maternal collapse has been a scenario within the training program since the beginning of the year and includes reference to the 4H’s and 4T’s.
There has been a strong commitment to learning from these events from the anaesthetic team as well as the wider MDT. The following points demonstrate that commitment:
a. Team learning at structured clinical governance events.
b. Inclusion of the management of tension pneumothorax in the regular SIM sessions for the anaesthetic trainees at St. Richard’s Hospital. This includes the significance of facial swelling and surgical emphysema. The trainers are planning SIM demonstrations of all the national anaesthetic regulation 28 notices and will play the recordings at teaching and clinical governance meetings.
c. The Trust’s anaesthetists have carefully reviewed The Royal College of Anaesthetists (RCA) guidance on the management of increased airway pressure for the ventilated patient which forms part of their Quick Reference Guide to Anaesthetic Emergencies Quick Reference Handbook (QRH) | The Association of Anaesthetists. Although the current handbook does not refer to surgical emphysema or tension pneumothorax in the management of increased airway pressures, we also note that, in their response to the PFD, the RCA and AA will share the learning that bilateral pneumothoraces can be a cause of failure to ventilate leading to cardiac arrest in the absence of trauma or thoracic surgery- through the SALG’s Patient Safety Update.
We believe that it is important that the evidence of , the obstetric anaesthetic expert witness at the inquest is considered as context to the findings of the Regulation 28 Report. verbatim comments reflect on the actions of the team and are shown below.
“I am satisfied that the medical team that responded and were working in the early hours of 10th September, their actions were reasonable and what was done, was done in a timely manner”.
“I am satisfied that the team were thinking what on earth could have caused this. There was anaphylaxis and or angioedema, as a combined diagnosis and they were thinking what has this patient had - a Caesarean section, Post-Partum Haemorrhage, therefore the H (Hypovolemia) due to massive blood loss was such they pre- emptively without any evidence of blood loss activated the major obstetrics haemorrhage plan, I think the 4 H’s and 4 T’s were being thought of.”
“Having read the statements and putting myself in the position of this team, although they were treating, it was not blind or obvious. I don’t think I would have stuck needles in the chest earlier. The opening of the abdomen was 2- fold; to release the gas but also to stop any bleeding. The most likely (cause of) deterioration of a woman who collapsed (on labour ward), looking as an obstetric anaesthetist, is that there has been some sort of catastrophic haemorrhage, because that is where the surgical activity has been, they opened the abdomen, released the gas and ROSC and there was no bleeding.”
(3) Investigation after Teegan’s Death The coroner raises the concern that there was no local investigation by the anaesthetic team before or after the HSIB report. However, initiating a local investigation in parallel to the HSIB investigation would have been contrary to national guidance. The Trust followed the recognised process for a maternal death and the incident was notified as a Serious Incident with a 72-hour report submitted at the appropriate time. This was followed by notification to HSIB. The incident fits the HSIB criteria, and the appropriate guidance was followed in response to the event. Of note, the guidance to Trusts from HSIB states: - Our maternity investigations have replaced a trusts' internal maternity serious incident investigations. We involve the trust and share the investigation reports as they are completed. Trusts continue to investigate maternity events that fall outside the specified criteria. (Information for trusts and staff — HSIB) The anaesthetic team cooperated fully with the HSIB investigation and responded comprehensively to the draft report. The outputs were discussed at length within the Trust in a number of forums and continues to be, including at the Intensive Care and Maternity Mortality and Morbidity meetings. This feedback was not fully reflected in the final report. Trust Clinical Governance Procedures Although the Trust followed existing national guidance, additional safeguards have been put in place to ensure our processes for investigating maternal deaths are robust. In the Regulation 28 notice, the Trust’s decision not to undertake a local investigation alongside the one initiated by HSIB is highlighted. At the inquest the Trust presented evidence demonstrating the very clear national guidance indicating that the HSIB investigation should replace the need for local scrutiny as described above. However, in response to the coroner’s concerns, the Trust has developed a draft SOP that defines the actions required when an HSIB investigation takes place
and includes consideration of the need or otherwise for a parallel local investigation. This will be ratified by the end of March 2023. As an organisation we are proud of our record of learning from deaths and working to improve preventable mortality. Improvements in mortality are both True North and Breakthrough Strategic Objectives at the trust – the latter with a specific focus on improving the recognition and management of the deteriorating patient. As an organisation, Learning from Deaths processes are well developed and scrutinised closely by our Quality Committee and Trust Board on a quarterly basis. In terms of wider learning in this specific case, senior representatives from the safety and clinical leadership teams, as well as the whole team of senior clinicians involved, attended the inquest and listened carefully throughout in this complex case. Factual accuracy We raise two matters in respect of the factual accuracy of the Regulation 28 Notice in respect of the following passage of text. ‘At or around 0545 with the enduring PEA cardiac arrest, an ongoing inability to ventilate by any means possible, and the continuing absence of chest movement and breath sounds on auscultation, the whole-body swelling was recognised to be due to surgical emphysema from a presumptive diagnosis of bilateral tension pneumothoraces. At or around 0548 hours bilateral thoracostomies were undertaken with return of spontaneous circulation.’ The Regulation 28 Report indicates that the PEA cardiac arrest began at 0510-0515 with a return of spontaneous circulation (ROSC) at 0548 which occurred with the treatment of the tension pneumothoraces. We believe the duration of the cardiac arrest and timing of the return of spontaneous circulation stated in the Regulation 28 report are inaccurate. Evidence provided by HSIB in their investigation report (p 27-28) indicates that ROSC occurred 13 minutes earlier at 0535. This is corroborated by the Defibrillator records that indicated that the cardiac arrest lasted 17 minutes. The evidence provided by the Trust based on the clinical record also indicated that ROSC occurred earlier than the coroner records, and when the abdomen was opened alleviating the intrabdominal pressure, prior the drainage of the tension pneumothoraces. Modern defibrillators provide real-time feedback on the quality of resuscitation, and it is of note that the analysis of the quality of CPR provided throughout the event was excellent with minimal interruptions. Summary In summary the Trust:
• Has developed and implemented a Maternity Improvement Program,
• Has achieved a very strong year 4 CNST submission.
• Has provided a robust program of training for the multidisciplinary group of staff working on our labour wards that prepares them for situations such as this.
• Has reviewed and strengthened processes for decision making about the local investigation of incidents referred to HSIB.
As an organisation we are committed to providing the highest quality maternity services and believe our commitment to the Maternity Improvement Program and achievements in governance, the Clinical Negligence Scheme for Trusts Year 4 submission and training for the multidisciplinary team demonstrate this. Finally, our thoughts and sympathy are with Teegan’s family; we recognise just how this has been the most traumatic event for them and on behalf of University Hospitals Sussex NHS FT, I want to extend my sincere condolences.
1. The resuscitation algorithm (4H’s and 4T’s) for PEA arrest
2. Surgical emphysema
3. The Investigation following Teegan’s death.
4. Trust Clinical Governance procedures.
Our responses are outlined below but also address matters of factual accuracy.
(1) The resuscitation algorithm and (2) surgical emphysema You have raised concerns that although there are 8 contributory causes of Pulseless Electrical Activity (PEA) cardiac arrest (the 4H’s and 4 T’s), only one of these, tension pneumothorax, also causes a sudden inability to ventilate a patient; it was therefore determined that there was a delay in the team identifying this as the cause of the PEA arrest. Concern has also been raised that there was a delay in the team identifying surgical emphysema despite the presence of indicative signs. The Trust has been copied into the PFD response from the Royal College of Anaesthetists and UK Anaesthetic Association and note their comment that Bilateral pneumothoraces occurring on emergence from a general anaesthetic, especially one for surgery that did not include thoracotomy or thoracoscopy, is so rare that most anaesthetists will never encounter such a situation. However, the Trust recognises that for staff to perform optimally in extremely challenging situations such as maternal cardiac arrest appropriate training is essential. The Trust has therefore taken action to ensure all the appropriate members of the Multi-Disciplinary Team (MDT) have received the necessary training to be able to manage obstetric emergencies. An audit conducted in January 2023 demonstrates that over 90% of the obstetric, anaesthetic and midwifery staff that work within the labour ward environment across the entire organisation had received this MDT training. This reaches the stringent standards set for training by the Clinical Negligence Scheme for Trusts year 4 requirements. Of note maternal collapse has been a scenario within the training program since the beginning of the year and includes reference to the 4H’s and 4T’s.
There has been a strong commitment to learning from these events from the anaesthetic team as well as the wider MDT. The following points demonstrate that commitment:
a. Team learning at structured clinical governance events.
b. Inclusion of the management of tension pneumothorax in the regular SIM sessions for the anaesthetic trainees at St. Richard’s Hospital. This includes the significance of facial swelling and surgical emphysema. The trainers are planning SIM demonstrations of all the national anaesthetic regulation 28 notices and will play the recordings at teaching and clinical governance meetings.
c. The Trust’s anaesthetists have carefully reviewed The Royal College of Anaesthetists (RCA) guidance on the management of increased airway pressure for the ventilated patient which forms part of their Quick Reference Guide to Anaesthetic Emergencies Quick Reference Handbook (QRH) | The Association of Anaesthetists. Although the current handbook does not refer to surgical emphysema or tension pneumothorax in the management of increased airway pressures, we also note that, in their response to the PFD, the RCA and AA will share the learning that bilateral pneumothoraces can be a cause of failure to ventilate leading to cardiac arrest in the absence of trauma or thoracic surgery- through the SALG’s Patient Safety Update.
We believe that it is important that the evidence of , the obstetric anaesthetic expert witness at the inquest is considered as context to the findings of the Regulation 28 Report. verbatim comments reflect on the actions of the team and are shown below.
“I am satisfied that the medical team that responded and were working in the early hours of 10th September, their actions were reasonable and what was done, was done in a timely manner”.
“I am satisfied that the team were thinking what on earth could have caused this. There was anaphylaxis and or angioedema, as a combined diagnosis and they were thinking what has this patient had - a Caesarean section, Post-Partum Haemorrhage, therefore the H (Hypovolemia) due to massive blood loss was such they pre- emptively without any evidence of blood loss activated the major obstetrics haemorrhage plan, I think the 4 H’s and 4 T’s were being thought of.”
“Having read the statements and putting myself in the position of this team, although they were treating, it was not blind or obvious. I don’t think I would have stuck needles in the chest earlier. The opening of the abdomen was 2- fold; to release the gas but also to stop any bleeding. The most likely (cause of) deterioration of a woman who collapsed (on labour ward), looking as an obstetric anaesthetist, is that there has been some sort of catastrophic haemorrhage, because that is where the surgical activity has been, they opened the abdomen, released the gas and ROSC and there was no bleeding.”
(3) Investigation after Teegan’s Death The coroner raises the concern that there was no local investigation by the anaesthetic team before or after the HSIB report. However, initiating a local investigation in parallel to the HSIB investigation would have been contrary to national guidance. The Trust followed the recognised process for a maternal death and the incident was notified as a Serious Incident with a 72-hour report submitted at the appropriate time. This was followed by notification to HSIB. The incident fits the HSIB criteria, and the appropriate guidance was followed in response to the event. Of note, the guidance to Trusts from HSIB states: - Our maternity investigations have replaced a trusts' internal maternity serious incident investigations. We involve the trust and share the investigation reports as they are completed. Trusts continue to investigate maternity events that fall outside the specified criteria. (Information for trusts and staff — HSIB) The anaesthetic team cooperated fully with the HSIB investigation and responded comprehensively to the draft report. The outputs were discussed at length within the Trust in a number of forums and continues to be, including at the Intensive Care and Maternity Mortality and Morbidity meetings. This feedback was not fully reflected in the final report. Trust Clinical Governance Procedures Although the Trust followed existing national guidance, additional safeguards have been put in place to ensure our processes for investigating maternal deaths are robust. In the Regulation 28 notice, the Trust’s decision not to undertake a local investigation alongside the one initiated by HSIB is highlighted. At the inquest the Trust presented evidence demonstrating the very clear national guidance indicating that the HSIB investigation should replace the need for local scrutiny as described above. However, in response to the coroner’s concerns, the Trust has developed a draft SOP that defines the actions required when an HSIB investigation takes place
and includes consideration of the need or otherwise for a parallel local investigation. This will be ratified by the end of March 2023. As an organisation we are proud of our record of learning from deaths and working to improve preventable mortality. Improvements in mortality are both True North and Breakthrough Strategic Objectives at the trust – the latter with a specific focus on improving the recognition and management of the deteriorating patient. As an organisation, Learning from Deaths processes are well developed and scrutinised closely by our Quality Committee and Trust Board on a quarterly basis. In terms of wider learning in this specific case, senior representatives from the safety and clinical leadership teams, as well as the whole team of senior clinicians involved, attended the inquest and listened carefully throughout in this complex case. Factual accuracy We raise two matters in respect of the factual accuracy of the Regulation 28 Notice in respect of the following passage of text. ‘At or around 0545 with the enduring PEA cardiac arrest, an ongoing inability to ventilate by any means possible, and the continuing absence of chest movement and breath sounds on auscultation, the whole-body swelling was recognised to be due to surgical emphysema from a presumptive diagnosis of bilateral tension pneumothoraces. At or around 0548 hours bilateral thoracostomies were undertaken with return of spontaneous circulation.’ The Regulation 28 Report indicates that the PEA cardiac arrest began at 0510-0515 with a return of spontaneous circulation (ROSC) at 0548 which occurred with the treatment of the tension pneumothoraces. We believe the duration of the cardiac arrest and timing of the return of spontaneous circulation stated in the Regulation 28 report are inaccurate. Evidence provided by HSIB in their investigation report (p 27-28) indicates that ROSC occurred 13 minutes earlier at 0535. This is corroborated by the Defibrillator records that indicated that the cardiac arrest lasted 17 minutes. The evidence provided by the Trust based on the clinical record also indicated that ROSC occurred earlier than the coroner records, and when the abdomen was opened alleviating the intrabdominal pressure, prior the drainage of the tension pneumothoraces. Modern defibrillators provide real-time feedback on the quality of resuscitation, and it is of note that the analysis of the quality of CPR provided throughout the event was excellent with minimal interruptions. Summary In summary the Trust:
• Has developed and implemented a Maternity Improvement Program,
• Has achieved a very strong year 4 CNST submission.
• Has provided a robust program of training for the multidisciplinary group of staff working on our labour wards that prepares them for situations such as this.
• Has reviewed and strengthened processes for decision making about the local investigation of incidents referred to HSIB.
As an organisation we are committed to providing the highest quality maternity services and believe our commitment to the Maternity Improvement Program and achievements in governance, the Clinical Negligence Scheme for Trusts Year 4 submission and training for the multidisciplinary team demonstrate this. Finally, our thoughts and sympathy are with Teegan’s family; we recognise just how this has been the most traumatic event for them and on behalf of University Hospitals Sussex NHS FT, I want to extend my sincere condolences.
Noted
Health Education England expresses condolences but states the concerns fall outside its remit, highlighting work on patient safety training and collaboration on broader NHS improvements. (AI summary)
Health Education England expresses condolences but states the concerns fall outside its remit, highlighting work on patient safety training and collaboration on broader NHS improvements. (AI summary)
View full response
Dear Dr Karen Henderson
RE: – Regulation 28 Report - Teegan Marie Barnard
I write in response to your report of 17 January 2023, made under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. I have been asked to respond on behalf of Health Education England. Please may I start by offering my sincere condolences to the family of Teegan Marie Bernard, following her tragic death. However, having carefully considered the report, together with the facts of the case, we believe that whilst there are valuable lessons to be learned; Unfortunately, these do not come within the scope of HEE’s current role and statutory responsibilities.
Your report raises concerns regarding both the care Teegan Marie Bernard received, together with the handling of evidence shortly after her death and the Trust’s obligations in relation to its statutory Duty of Candour. Your report also highlighted concerns around the Trust’s procedures and process for investigating an unexpected death. We acknowledge that the Chief Executive of Health Education England (HEE) has been identified as having a duty to respond and the report has also been sent by the coroner to other national bodies including:
• , Chief Executive U. Hospitals Sussex NHS Foundation Trust
• , Medical Director, St Richards Hospital, Chichester
• The Chief Executive NHS England
• The Chief Executive of the Care Quality Commission.
• President, Royal College of Anaesthetists
• President, Association of Anaesthetists Great Britain, and Ireland To respond to your concerns, I will first clarify HEE’s current role in relation to the education and training of the medical, nursing and health workforce. HEE is currently a non-departmental public body accountable to the Secretary of State and Parliament. On the 1 April 2023, Health Education England will become part of a new organisation within NHS England. As part of the NHS, we work with partners to plan, recruit, educate and train the health workforce. HEE’s primary functions will continue; this being to serve the people of England by educating, training, and developing healthcare professionals. However, HEE does not have responsibility for decisions on the local NHS workforce or resources and nor do we mandate training or clinical procedure for consultant medical staff, this is the responsibility of local NHS Trusts.
We recognise that both the Ockenden Report and the review and report into maternity and neonatal services in East Kent: 'Reading the signals,’ have placed a much-needed focus on what now must be done to raise standards of care in maternity services. We are working to implement the Immediate Action Areas in the Ockenden Report. This includes the recommendation that the Department of Health & Social Care (DHSC) must work with the Royal College of Obstetricians and Gynaecologists (RCOG) and HEE to consider how to deliver an adequate and sustainable level of obstetric training posts to enable trusts to deliver safe obstetric staffing over the years to come.
Regarding the independent investigation led by into failures in East Kent; like our system partners we are working at pace to ensure the four areas for action are considered and implemented:
• identifying poorly performing units
• giving care with compassion and kindness
• teamworking with a common purpose
• responding to challenge with honesty HEE, together with our system partners acknowledge there are areas where the NHS must do much better and this is now informing our approach, in delivery of the workforce of the next 15 years.
I would like to draw your attention to the work, which HEE has led on, around training in patient safety. This carefully designed training series is designed to be used by staff and clinical practitioners at all stages of their career and regardless of whether their roles are patient facing or not. This is because we believe that patient safety is everyone’s business. Patient safety training materials have been developed by Health Education England, with NHS England and NHS Improvement, The Academy of Medical Royal Colleges and e-learning for healthcare. Completion of this training is helping to ensure health and care services will be made as safe as possible for patients and service users.
I hope this response provides assurance that steps are being taken to improve patient safety, together with ensuring the workforce has the appropriate knowledge and skills to deliver the very best patient outcomes. This is in line with the NHS Long Term Plan priority areas.
Finally, on behalf of HEE, I thank you for bringing these matters to our attention and the awareness of others.
RE: – Regulation 28 Report - Teegan Marie Barnard
I write in response to your report of 17 January 2023, made under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. I have been asked to respond on behalf of Health Education England. Please may I start by offering my sincere condolences to the family of Teegan Marie Bernard, following her tragic death. However, having carefully considered the report, together with the facts of the case, we believe that whilst there are valuable lessons to be learned; Unfortunately, these do not come within the scope of HEE’s current role and statutory responsibilities.
Your report raises concerns regarding both the care Teegan Marie Bernard received, together with the handling of evidence shortly after her death and the Trust’s obligations in relation to its statutory Duty of Candour. Your report also highlighted concerns around the Trust’s procedures and process for investigating an unexpected death. We acknowledge that the Chief Executive of Health Education England (HEE) has been identified as having a duty to respond and the report has also been sent by the coroner to other national bodies including:
• , Chief Executive U. Hospitals Sussex NHS Foundation Trust
• , Medical Director, St Richards Hospital, Chichester
• The Chief Executive NHS England
• The Chief Executive of the Care Quality Commission.
• President, Royal College of Anaesthetists
• President, Association of Anaesthetists Great Britain, and Ireland To respond to your concerns, I will first clarify HEE’s current role in relation to the education and training of the medical, nursing and health workforce. HEE is currently a non-departmental public body accountable to the Secretary of State and Parliament. On the 1 April 2023, Health Education England will become part of a new organisation within NHS England. As part of the NHS, we work with partners to plan, recruit, educate and train the health workforce. HEE’s primary functions will continue; this being to serve the people of England by educating, training, and developing healthcare professionals. However, HEE does not have responsibility for decisions on the local NHS workforce or resources and nor do we mandate training or clinical procedure for consultant medical staff, this is the responsibility of local NHS Trusts.
We recognise that both the Ockenden Report and the review and report into maternity and neonatal services in East Kent: 'Reading the signals,’ have placed a much-needed focus on what now must be done to raise standards of care in maternity services. We are working to implement the Immediate Action Areas in the Ockenden Report. This includes the recommendation that the Department of Health & Social Care (DHSC) must work with the Royal College of Obstetricians and Gynaecologists (RCOG) and HEE to consider how to deliver an adequate and sustainable level of obstetric training posts to enable trusts to deliver safe obstetric staffing over the years to come.
Regarding the independent investigation led by into failures in East Kent; like our system partners we are working at pace to ensure the four areas for action are considered and implemented:
• identifying poorly performing units
• giving care with compassion and kindness
• teamworking with a common purpose
• responding to challenge with honesty HEE, together with our system partners acknowledge there are areas where the NHS must do much better and this is now informing our approach, in delivery of the workforce of the next 15 years.
I would like to draw your attention to the work, which HEE has led on, around training in patient safety. This carefully designed training series is designed to be used by staff and clinical practitioners at all stages of their career and regardless of whether their roles are patient facing or not. This is because we believe that patient safety is everyone’s business. Patient safety training materials have been developed by Health Education England, with NHS England and NHS Improvement, The Academy of Medical Royal Colleges and e-learning for healthcare. Completion of this training is helping to ensure health and care services will be made as safe as possible for patients and service users.
I hope this response provides assurance that steps are being taken to improve patient safety, together with ensuring the workforce has the appropriate knowledge and skills to deliver the very best patient outcomes. This is in line with the NHS Long Term Plan priority areas.
Finally, on behalf of HEE, I thank you for bringing these matters to our attention and the awareness of others.
Sent To
- Care Quality Commission
- Health Education England
- NHS England
- St Richards Hospital
- University Hospitals Sussex NHS Foundation Trust
Response Status
Linked responses
6 of 5
56-Day Deadline
14 Mar 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 7th January 2022 I resumed an investigation into the death of Teegan Marie Barnard. On 14th December 2022 I concluded the Investigation. The medical cause of death given was: 1a. Acute Bronchopneumonia 1b. Global Cerebral Hypoxia 1c. In Hospital Cardiac Arrest following Third Trimester Lower Segment Caesarean Section, Significant Post-Partum Haemorrhage and Perioperative Bilateral Tension Pneumothoraces I determined: On 7th October 2019 Teegan Marie Barnard died at her home address in Havant. She sustained an irrecoverable hypoxic brain injury following a prolonged pulseless electrical activity (PEA) cardiac arrest during emergence from a general anaesthetic after an emergency lower segment caesarean section (LSCS) on 9th September 2019 at St Richards Hospital, Chichester. The PEA cardiac arrest was due to bilateral tension pneumothoraces, the cause of which remains unclear, but in circumstances whereby a delay in the recognition and treatment thereof made a material contribution to Teegan’s death. CIRCUMSTANCES OF THE DEATH Teegan became pregnant in December 2018 and was admitted in the early stages of labour to the delivery suite at St Richard’s Hospital, Chichester on 8th September 2019. Labour did not progress and a category 2 LSCS was undertaken at or around 0300 on 9th September 2019 by way of general anaesthesia as the spinal anaesthetic was ineffective.
At LSCS, Teegan was found to have had an obstructed pregnancy with an atonic uterus, sustaining a significant post-partum haemorrhage of approximately four litres. This was treated with pharmacological and surgical interventions.
The surgery was concluded at or around 0430 hours. Teegan was clinically stable with all physiological parameters, including airway pressures, within normal limits. A decision was made to awaken Teegan from the anaesthetic. This included reversal of neuromuscular blockade, with transfer to ventilator pressure support mode with delivery of 100 % oxygen. At or around 0500 hours, Teegan remained intubated and had been transferred from the operating table onto her bed. After transfer and on turning Teegan to be cleaned, the ventilator high airway pressure alarm sounded, and Teegan’s oxygen saturation fell. Attempts to ventilate Teegan by the ventilator or by hand and with a separate breathing circuit were not successful. She was deeply cyanotic and had begun to swell, at first in and around her head and neck and thereafter throughout her whole body. No breath sounds were heard on auscultation and despite strenuous attempts at ventilation, her chest was not moving. Shortly thereafter, at or around 0510-0515 hours, Teegan had a pulseless electrical activity (PEA) cardiac arrest.
Teegan was thought to have developed anaphylaxis for which treatment was given but without resolution or improvement in her clinical condition. At or around 0545 with the enduring PEA cardiac arrest, an ongoing inability to ventilate by any means possible, and the continuing absence of chest movement and breath sounds on auscultation, the whole-body swelling was recognised to be due to surgical emphysema from a presumptive diagnosis of bilateral tension pneumothoraces. At or around 0548 hours bilateral thoracostomies were undertaken with return of spontaneous circulation.
Unfortunately, given the length of time of the cardiac arrest, Teegan sustained a non-survivable hypoxic brain injury and sadly died at home six weeks later, on 7th October 2019. She was 17 years of age at the time of her death.
At LSCS, Teegan was found to have had an obstructed pregnancy with an atonic uterus, sustaining a significant post-partum haemorrhage of approximately four litres. This was treated with pharmacological and surgical interventions.
The surgery was concluded at or around 0430 hours. Teegan was clinically stable with all physiological parameters, including airway pressures, within normal limits. A decision was made to awaken Teegan from the anaesthetic. This included reversal of neuromuscular blockade, with transfer to ventilator pressure support mode with delivery of 100 % oxygen. At or around 0500 hours, Teegan remained intubated and had been transferred from the operating table onto her bed. After transfer and on turning Teegan to be cleaned, the ventilator high airway pressure alarm sounded, and Teegan’s oxygen saturation fell. Attempts to ventilate Teegan by the ventilator or by hand and with a separate breathing circuit were not successful. She was deeply cyanotic and had begun to swell, at first in and around her head and neck and thereafter throughout her whole body. No breath sounds were heard on auscultation and despite strenuous attempts at ventilation, her chest was not moving. Shortly thereafter, at or around 0510-0515 hours, Teegan had a pulseless electrical activity (PEA) cardiac arrest.
Teegan was thought to have developed anaphylaxis for which treatment was given but without resolution or improvement in her clinical condition. At or around 0545 with the enduring PEA cardiac arrest, an ongoing inability to ventilate by any means possible, and the continuing absence of chest movement and breath sounds on auscultation, the whole-body swelling was recognised to be due to surgical emphysema from a presumptive diagnosis of bilateral tension pneumothoraces. At or around 0548 hours bilateral thoracostomies were undertaken with return of spontaneous circulation.
Unfortunately, given the length of time of the cardiac arrest, Teegan sustained a non-survivable hypoxic brain injury and sadly died at home six weeks later, on 7th October 2019. She was 17 years of age at the time of her death.
Copies Sent To
1. See names in paragraph 1 above
3. Clinical Director, Anaesthetics, St Richards Hospital, Chichester
4. ex
CEO, UHS NHS Foundation Trust
5. Chairman, Board of Governors, UHS NHS Foundation Trust
6. President, Royal College of Anaesthetists
7. President, Association of Anaesthetists Great Britain and Ireland
8. General Medical Council
9. HSIB
Signed
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.