Mollie Dimmock
PFD Report
All Responded
Ref: 2021-0379
All 1 response received
· Deadline: 4 Jan 2022
Coroner's Concerns (AI summary)
NICE Guidance NG121 lacks a clear definition for "large-for-gestational-age" babies, leading to inconsistent interpretation and application of delivery mode guidance. This creates uncertainty in crucial obstetric care decisions.
View full coroner's concerns
NICE Guidance NG121 last updated 25 April 2019 relates to intrapartum care for women with existing medical conditions or obstetric complications and their babies. Within this Guidance, whist there is reference at paragraph 1.17 to guidance in respect mode of birth for large-for-gestational-age babies, there is no definition of a large-for-gestational-age baby in the Guidance. There does not appear to be any national guidance or accepted definition of large for-gestational-age such that application of the Guidance is open to interpretation and variation depending upon an NHS Trust's own policies and guidance, and, in turn, the interpretation of obstetricians and other clinicians advising potential parents in anticipation of delivery modes. It is clear that NG121 is intended to provide guidance in relation to many potential scenarios which may impact upon care and mode of delivery decisions. The uncertainty surrounding when section 1.17 of the Guidance should be relevant arises through the lack of a definition of a large-for-gestational-age baby. Application of section 1.17 of the Guidance includes consideration of shoulder dystocia and options for continuing labour or caesarean section relevant to both the life of the mother and the baby.
Responses
Noted
NICE acknowledges the coroner's concerns regarding the lack of a standard definition for "large for gestational age" in its guideline on intrapartum care, but argues that providing a specific cut-off would convey inappropriate certainty. (AI summary)
NICE acknowledges the coroner's concerns regarding the lack of a standard definition for "large for gestational age" in its guideline on intrapartum care, but argues that providing a specific cut-off would convey inappropriate certainty. (AI summary)
View full response
Dear Mr Butler,
I write in response to your regulation 28 report of 9 November 2021 regarding the very sad death of Molly Dimmock. I would like to express my sincerest condolences to her family.
In your report you state that, while NICE’s clinical guideline on intrapartum care for women with existing medical conditions or obstetric complications and their babies [NG121] makes recommendations on the mode of birth for large-for-gestational-age babies, as there is no standard definition of large for gestational age, the guidance is open to interpretation and is inconsistently applied.
During the development of NG121, the committee acknowledged that there is a lot of uncertainty around the diagnosis of large for gestational age. There is no standardised definition and clinical suspicion of large for gestational age, particularly during labour, is subjective and often inaccurate. While ultrasound estimation of fetal weight is likely to be more accurate, it is difficult to perform accurately during labour.
Given this uncertainty the committee felt it was important to give the woman balanced information to support shared decision making. The discussion between healthcare professionals and a woman with a baby suspected of being large for gestational age should focus not only on the potential risk of adverse outcomes for the woman and the baby, but also on the uncertainty around the diagnosis of a large-for-gestational-age baby and what it might mean for the woman and her baby if such problems did occur.
We believe that if the guideline were to provide a cut off it would be liable to convey inappropriate certainty, or reassurance if the cut off is not reached. As such, we do not believe that any action is required of NICE.
I write in response to your regulation 28 report of 9 November 2021 regarding the very sad death of Molly Dimmock. I would like to express my sincerest condolences to her family.
In your report you state that, while NICE’s clinical guideline on intrapartum care for women with existing medical conditions or obstetric complications and their babies [NG121] makes recommendations on the mode of birth for large-for-gestational-age babies, as there is no standard definition of large for gestational age, the guidance is open to interpretation and is inconsistently applied.
During the development of NG121, the committee acknowledged that there is a lot of uncertainty around the diagnosis of large for gestational age. There is no standardised definition and clinical suspicion of large for gestational age, particularly during labour, is subjective and often inaccurate. While ultrasound estimation of fetal weight is likely to be more accurate, it is difficult to perform accurately during labour.
Given this uncertainty the committee felt it was important to give the woman balanced information to support shared decision making. The discussion between healthcare professionals and a woman with a baby suspected of being large for gestational age should focus not only on the potential risk of adverse outcomes for the woman and the baby, but also on the uncertainty around the diagnosis of a large-for-gestational-age baby and what it might mean for the woman and her baby if such problems did occur.
We believe that if the guideline were to provide a cut off it would be liable to convey inappropriate certainty, or reassurance if the cut off is not reached. As such, we do not believe that any action is required of NICE.
Sent To
- National Institute for Health and Care Excellence
Response Status
Linked responses
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56-Day Deadline
4 Jan 2022
All responses received
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Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 3rd July 2020, I commenced an Investigation into the death of Mollie Daisy DIMMOCK, who died at 03: 11 on 25th June 2020 at Stoke Mandeville Hospital, 34 minutes after being delivered. The Investigation concluded at the end of the Inquest on 14th October 2021. The medical cause of death was confirmed as:
C.G.BUTLER SENIOR CORONER · BUCKINGHAMSHIRE 1 a Perinatal asphyxia
C.G.BUTLER SENIOR CORONER · BUCKINGHAMSHIRE 1 a Perinatal asphyxia
Circumstances of the Death
Molly's death was confirmed when she was 34 minutes old at 03: 11 on 25th June 2020 at Stoke Mandeville Hospital from perinatal asphyxia due to hypoxia caused by umbilical cord compression from shoulder dystocia which lasted for five minutes before Molly was fully delivered . A narrative conclusion was recorded : Molly was a large for gestation age baby. On the balance of probabilities, comparison between the 20 week and 36 week ultrasound scans demonstrate accelerated fetal growth . Retrospective review of the 36 week scan by the Health Safety Investigation Branch clinical panel considered that the abdominal circumference of Molly was under measured and this led to an under estimation of her fetal weight. Molly's mother was not referred for obstetric consultation following the 36 week scan . The first opportunity for an obstetric discussion with Molly's parents about the risks of delivery came late in labour, early on the morning of delivery. On balance, Molly's parents did not have the understanding that shoulder dystocia was a risk. The option of proceeding straight to a caesarean section was not offered to Molly's parents and consent was procured on the basis of a trial delivery with Kiel land's forceps, only with caesarean section as an option thereafter. Molly's head was delivered at 02 :31 and shoulder dystocia was identified. Molly's body was delivered five minutes thereafter with the umbilical cord wrapped around her neck. Molly was unresponsive, although there was evidence of a heartbeat reported, and, notwithstanding attempts to resuscitate her, she was confirmed to have died 34 minutes after delivery. The risk of shoulder dystocia was heightened by Molly's size. Coroner's Office, 29 Windsor End, Beaconsfield, Buckinghamshire . HP9 2JJ
C.G.BUTLER SENIOR CORONER • BUCKINGHAMSHIRE
C.G.BUTLER SENIOR CORONER • BUCKINGHAMSHIRE
Action Should Be Taken
C.G.BUTLER SENIOR CORONER • BUCKINGHAMSHIRE
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.