Brandon-Robert Collins-Hayward
PFD Report
All Responded
Ref: 2021-0088
All 2 responses received
· Deadline: 25 May 2021
Coroner's Concerns (AI summary)
Absence of national guidance for postnatal home visits to include basic newborn observations and for medical assessment of babies when mothers are admitted with potential sepsis creates future death risks.
View full coroner's concerns
1. During the inquest evidence was heard that: i. The deceased was assessed at his home address on the 3rd June by the midwifery team at aged 5 days. At this assessment there was a visual check done but no basic observation assessments taken, such as temperature, heart rate and respiration rate, from the deceased or his mother to confirm their wellbeing ii. Evidence was given at the Inquest that there is no guidance nationally for such checks to be undertaken but following a review by University Hospital Dorset NHS Foundation Trust (UHD) who provided the postnatal care to mother and baby, they have reviewed their local policy to ensure these observations are taken in the early days following birth to ensure their wellbeing.
iii. The local policy in place at UHD, titled “Postnatal Care Guideline”, now provides guidance that at each visit up to day 10 post birth, a full set of baby and maternal observations are to be taken. Evidence was given at the Inquest that there would be great benefit in such guidance being provided nationally to ensure prompt medical care is provided and to prevent future deaths.
iv. In addition evidence was given during the Inquest that the deceased’s Mother was admitted to hospital on the 6th June 2019, with moderate to severe infection and was noted to be a high risk of developing sepsis. Following this admission, the deceased was not medically assessed for possible infection prior to his cardiac arrest the following morning.
v. Evidence was given at the Inquest that there is no guidance nationally for babies to be medically assessed when a mother is admitted to hospital. Following the review by UHD, they have put in place a local policy titled “Caring for Newly Delivered Women and their babies outside the Maternity Unit” which provides guidance to be applied when a women presents at the hospital within 28 days following the birth.
vi. This advises that when a mother is admitted to a UHD Hospital, the baby should be medically reviewed either in hospital, or at home by the midwifery team, to ensure the medical wellbeing of the baby. Evidence was given at the Inquest that there would be great benefit in such guidance being provided nationally to ensure prompt medical care is provided and to prevent future deaths.
2. I have concerns with regard to the following: i. I am concerned that due to the lack of national guidance regarding close monitoring of mothers and babies following discharge after birth, and the fact that there is no national guidance for a medical assessment of a baby when the mother is admitted to hospital with potential sepsis, there could be a death in the future.
ii. I would therefore request there is a review of the guidance in place for post-natal care following the discharge from hospital in the immediate time following the birth, namely 10 days and a review of the national guidance in place when a mother is admitted to hospital within 28 days of birth, especially when diagnosed with infection and at high risk of developing sepsis.
iii. The local policy in place at UHD, titled “Postnatal Care Guideline”, now provides guidance that at each visit up to day 10 post birth, a full set of baby and maternal observations are to be taken. Evidence was given at the Inquest that there would be great benefit in such guidance being provided nationally to ensure prompt medical care is provided and to prevent future deaths.
iv. In addition evidence was given during the Inquest that the deceased’s Mother was admitted to hospital on the 6th June 2019, with moderate to severe infection and was noted to be a high risk of developing sepsis. Following this admission, the deceased was not medically assessed for possible infection prior to his cardiac arrest the following morning.
v. Evidence was given at the Inquest that there is no guidance nationally for babies to be medically assessed when a mother is admitted to hospital. Following the review by UHD, they have put in place a local policy titled “Caring for Newly Delivered Women and their babies outside the Maternity Unit” which provides guidance to be applied when a women presents at the hospital within 28 days following the birth.
vi. This advises that when a mother is admitted to a UHD Hospital, the baby should be medically reviewed either in hospital, or at home by the midwifery team, to ensure the medical wellbeing of the baby. Evidence was given at the Inquest that there would be great benefit in such guidance being provided nationally to ensure prompt medical care is provided and to prevent future deaths.
2. I have concerns with regard to the following: i. I am concerned that due to the lack of national guidance regarding close monitoring of mothers and babies following discharge after birth, and the fact that there is no national guidance for a medical assessment of a baby when the mother is admitted to hospital with potential sepsis, there could be a death in the future.
ii. I would therefore request there is a review of the guidance in place for post-natal care following the discharge from hospital in the immediate time following the birth, namely 10 days and a review of the national guidance in place when a mother is admitted to hospital within 28 days of birth, especially when diagnosed with infection and at high risk of developing sepsis.
Responses
Action Planned
NICE guidelines on postnatal care and neonatal infection were being updated to address concerns about monitoring mothers/babies after discharge and assessing babies when mothers are admitted with infection. The Royal College of Paediatrics and Child Health will continue to advocate for adequate resources in child health. (AI summary)
NICE guidelines on postnatal care and neonatal infection were being updated to address concerns about monitoring mothers/babies after discharge and assessing babies when mothers are admitted with infection. The Royal College of Paediatrics and Child Health will continue to advocate for adequate resources in child health. (AI summary)
View full response
Dear Ms Griffin, write in response to your correspondence; dated December 2020, regarding the sad death of Brandon-Robert William Collins-Hayward. Our thoughts are with his family. We have considered the circumstances surrounding Brandon-Robert's death; and the concerns raised in your report ~ namely, whether there is sufficient guidance relating to the monitoring of mothers and babies in the immediate time following discharge from hospital after birth; and the assessment of babies when the mother is admitted to hospital within 28 days of birth (especially when diagnosed with infection and at high risk of developing sepsis): We consider that there are 2 NICE guidelines of relevance: NICE has published a clinical guideline on postnatal care up_to 8 weeks after birth (CG3Z) This guideline covers the routine postnatal care that women and their babies should receive for 6-8 weeks after the birth. It includes advice given on breastfeeding, and the management of common and serious health problems in women and their babies after the birth. This guideline is currently in the process of being updated: NICE also has a guideline on neonatal infection: antibiotics for prevention and treatment (CG149) This guideline covers preventing infection within 72 hours of birth in healthy babies, treating pregnant women whose baby is at risk, and caring for babies who have a suspected or confirmed infection: This guideline is also currently in the process of being updated, and the guideline's scope has been extended to cover late neonatal infection (>72 hours to 28 days): NICE
nice@nice.org.uk Your very
Therefore, the concerns you have raised following Brandon-Roberts tragic death will be further considered by the guideline developers as part of this ongoing work We expect to publish both updated guidelines later this The NICE website will be updated with further developments Yours sincerely , Professor Chief Executive Page | 2 year:
RC Royal College of General Practitioners GP Dr Joint Flonorary Secretary Mrs Rachael Clare Griffin HM Senior Coroner For the Coroner Area of Dorset Sent by email to: March 2021 Dear Mrs Griffin, Regulation 28 Report to Prevent Future Deaths - touching on the death of Brandon-Robert William Collins-Hayward Thank you for your letter of 23 February 2021. am responding on behalf of the Royal College of General Practitioners as Joint Honorary Secretary to Council: Firstly, can convey our condolences to the family and friends of baby Brandon-Robert William Collins-Hayward: was saddened to read of Brandon's passing: The report's recommendations for better national guidance regarding the monitoring of mothers and babies following discharge after birth, and that babies are medically assessed when a mother is admitted to hospital, seem sensible but the Royal College of Midwives, the Institute of Health Visitors and the Royal Colleges of Emergency medicine and of Physicians may be in a better position to commend on these: General practitioners (GPs) usually undertake the postnatal check for mothers and babies slightly later at 6-8 weeks. Of course, patients can contact their GP earlier if they have any concerns but in terms of routine checks, earlier checks than 6-8 weeks tend to be undertaken by midwives and health visitors: trust that this reply is helpful and if you have any questions, please do not hesitate to contact me_ Yours sincerely, "llis Dr Joint Honorary Secretary of Council Royal College of General Practitioners Royal College of General Practitioners 30 Euston Square; London; NW1 2FB Tel: 020 3188 7400 info@rcgp.org.uk rcgp org.uk Patron: HRH The Duke of Edinburgh Registered Charity Number 223106
THE Royal COLLEGE OF MIDWIVES Promoting Supporting Influencing Coroner's Support Officer The Coroner's Office for the County of Dorset Bournemouth Town Hall Bournemouth BH2 6DY By Email to: 29 January 2021 Dear Re: Regulation 28 report_into the death of baby Brandon-Robert _William Collins-Hayward Thank vou for vour letter dated the 19th January outlining a request from H.M Coroner Mrs R.C Griffin, with reference to a Section 28- to prevent further death touching on the death of Brandon- Robert William Collins-Hayward: The RCM was saddened to read about the tragic death of baby Brandon. We note that the direction of the Section 28 to us was undertaken in faith by Vice President RCOG, however the RCM is a membership organisation and trade union; we have no jurisdiction over the education, employment or registration of maternity staff. The remit for the development and implementation of any new NHS guidance would sit with NHS Improvement The RCM hopes that this signposting will support the Coroners actions going forward. Please do not hesitate to make contact if the RCM can be of any further assistance. sincerely, Dr Executive Director for Services to Members The Royal College of Midwives 0300 303 0444 Open 24 hours a day; days week 10-18 Union Street +44 20 7312 3536 disability London E: info@remorg uk confident Wag pmo Stonewall SEI ISZ W: wwwrcmorg uk COMMITTED Lecilancacchmaenennn Chief Executive: President: Patron: HRH The Princess Royal; The Royal College of Midwives: coipany liited by guarantee. Registered No. 00030157 good Yours Living
iHV Institute of Health Visiting Excellence in Practice Institute of Health Visiting c/o Royal Society for Public Health, 59 Mansell St, E1 8AN 27th January 2021 Rachael Clare Griffin HM Senior Coroner for the Coroner Area of Dorset Dear Ms Griffin; Re: Regulation 28 report into the death of baby Brandon-Robert William Collins-Hayward Thank you for your email dated 19th January 2021 requesting a response to your inquest findings Your attached Regulation 28 Report contains details of the sad death of baby Brandon-Robert William Collins-Hayward in June 2019, when he was 9 days ld, with the medical cause of death recorded as Escherichia coli sepsis. In England, the midwife will be responsible for the care of the mother and infant in the immediate post-natal period. The midwife would normally discharge the mother and baby dyad from their caseload between the 10" and 14th day following the birth. At this point, the care of the dyad would be transferred to the health visiting service, although midwifery care can be extended up to 28 days after the birth if the or mother is unwell or has additional needs which require support from the midwifery team. As Brandon-Robert William Collins-Hayward sadly died 9 days after his birth, and he became unwell at home, his community care would fall within the remit of the midwifery service and GP; at this point his care would not have transferred to the health visiting service. However what you ask for is for national learning from this sad case: NICE produce national guidance used by all the relevant professionals: 'Normal Postnatal Care' covers the postnatal period for mother and baby up until 8 weeks post partum_ We note that you have already written to NICE Whilst there is a time lag with their process this would seem the most efficient way of ultimately getting the messaging out to all the relevant professionals who will base their own guidance on that produced by NICE: There is also national guidance produced by Public Health England on identifying sepsis in babies which health visitors will use to inform their practice you can find details here if you haven't already been alerted to it: https ILassets publishing service gov uk/government/uploads/system/uploadslattachment_data/file/648381/Se psis_guidance_for_health_professionals_and_school_nursespdf Paediatricians are the professional group with the greatest expertise in the care of the newborn, again note you have already written to their Royal College. However it will be GPs and midwives in the community who may make most use from guidance regarding observing the baby's health when admitting a mother with suspected sepsis before the baby is 10-14 days old and note that the RCOG have advised that Vou also writing to their colleges. We share your ambition that learning from this case should be used to prevent future deaths due to sepsis and appreciate you alerting Us. Sepsis is a life-threatening condition in young babies which is difficult to spot and can lead to a rapid deterioration in the baby'$ condition requiring urgent medical treatment: baby any
We do hope that writing to NICE will ultimately deliver the national change you require, alongside alerting the Royal Colleges of Paediatrics, Midwifery and General Practice the latter two may have their own guidance on managing sepsis in the mother (something that we don't have) which can be adjusted immediately for future care also of the infant: If you require any further information, do not hesitate to contact US, Kind regards Dr CBE Executive Director Cc Chair of the iHV
5-11 Theobalds Road XRCPCH WCOndSn Royal College of Phone: 020 7092 6000 Paediatrics and Child Health Fax: 020 7092 6001 Leading the way in Children Health WWW t rcpch ac.uk Monday, 01 February 2021 Sent by email to= Dear Coroner Rachel Clare Griffin Re: Investigation into the death of Brandon-Robert William Collins-Hayward Regulation 28 - Action to Prevent Future Deaths have carefully read your report regarding the tragic and untimely death of Brandon-Robert William Collins-Hayward and would like to first express my sincere condolences to his family. We have been provided with limited details regarding the circumstances of his death and appreciate that many ofthe details covered in the inquest were omitted for brevity_ have discussed the findings of the investigation with senior colleagues within the RCPCH: From your report we have specifically noted: On 3 of life following a normal vaginal delivery, he started to make grumbling noises, developed a shiver and reduced his milk intake: On 5 of life, he was assessed at home by the midwifery team when a visual check, but no basic observations were performed. On 8 of life, his mother was admitted to hospital with moderate to severe infection and at high risk of developing sepsis, but he was not referred for medical assessment for possible infection: On 9 of life, he was yellow in colour, had a yellow discharge in his nappy and started to struggle breathing: Cardiopulmonary resuscitation was commenced, and he arrived at hospital in a peri-arrest condition and received active treatment with continued resuscitation attempts_ It would seem from the report that Brandon-Robert developed overwhelming sepsis in a short period of time. On a clinical level, with the information provided, it seems difficult to directly link the findings on 3 and 5 of life with the tragic outcomes of this case: In infants under one month of age with sepsis, there could only be hours from the onset of abnormal observations to collapse: Occasionally there are cases of more slowly evolving infection, but with gram negative organisms such as Escherichia Coli, disease progression can be alarmingly fast. From the information provided, it appears that the potential time for intervention may have been around the hospital admission of Brandon-Robert's mother. However; the cause of sepsis in Brandon-Robert's mother that required her admission on the 6th June 2019 is not clear in the report we received, and it does not state whether the same causative organism was involved in both cases. Post-partum infection is not uncommon, and Escherichia Coli is one of many potential Page of 5 Day Day Day Day Day Day
causes The Royal College of Obstetricians and Gynaecologists' guideline 64b* only recommends treatment for the newborn if either Group A Streptococcus, Group B Streptococcus, some forms of Staphylococci, or Neisseria Meningitides are identified in the mother. Details were provided on the response the hospital Trust following this case and | recognise ~changes have been made to local policies and procedures to ensure observations of babies are taken up to 10 following birth, and babies of mothers admitted to hospital within 28 days of birth are medically reviewed either in hospital or at home by the midwifery team. You have asked the RCPCH, Royal College of Obstetricians and Gynaecologists (RCOG) and National Institute of Clinical Excellence (NICE) to review current national guidance in place for post-natal care following discharge from hospital after birth. It is advised that national guidance should be in place to perform observations on babies at each review within the first 10 days of life and medical assessment ofa baby should be required when the mother is admitted to hospital with potential sepsis within 28 of birth: National guidance recommendations Medical Royal Colleges are membership-based professional bodies, which set the standards for training of specialist doctors in some or all parts of the UK and contribute to the further development of professional medical practice As such, the RCPCH is unable to comment on specifics of the case relating to the practice of other healthcare professions and specialties beyond paediatrics. Alongside setting standards for paediatric doctors, RCPCH and affiliated specialty groups provide expert clinical input to the development of service and clinical standards. In England the most widely recognised national guidelines and standards are developed by NICE which has a rigorous and systematic process for topic selection, identifying evidence, evidence synthesis, development, consultation, and final production: Standards are developed in collaboration with expert clinical groups and stakeholders, including Medical Royal Colleges. The RCOG guideline 64b on bacterial sepsis following pregnancy was last updated in 2012. The NICE clinical guideline CG372 was last updated in February 2015 and covers the routine postnatal care women and their babies should receive for 6-8 weeks after birth: The RCPCH provided formal support for NICE quality standard 05373 that was last updated in June 2015, which describes high- quality care in priority areas for the routine postnatal care of women and their babies We support your recommendation to review these national guidelines and advise this includes: a review of the current list of organisms found in mothers that should lead to mandatory treatment of the infant: a review of current guidance on the type, frequency and formality of observational recording in new mother baby pairs: a review of potential trigger points for referral of newborns to other clinical teams. Of note, there may be significant national resource implications to completing a full set of neonatal and maternal observations on each postnatal visit. This would add around 10 minutes to each postnatal consultation for the 600,000 or so deliveries per year in England:
https:I WWw.nice org uklguidance/qs37
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We would ask that both RCOG and NICE review and update their national guidance to include these considerations. The RCPCH would be pleased to contribute to this work and provide support where appropriate NHS bodies and individual clinical departments are also expected to ensure that their operational activities comply with NICE and RCOG guidelines: We would emphasise that there should be in place in all NHS organisations clear systems and processes for clinical governance that monitor and audit practice and outcomes. These arrangements should also ensure that clinicians of all professions practice under the latest national guidance: RCPCH support for healthcare professionals am pleased to set out below additional work that has been undertaken to develop guidance in the relevant areas where RCPCH can make a difference_ This includes advocating for adequate training of all healthcare professionals reviewing children and supporting the development of resources to provide appropriate clinical decision support for healthcare professionals. In 2014,the RCPCH, British Association for Child & Adolescent Public Health and National Children's Bureau released a joint report titled 'Why Children Die"4. It examines some of the possible reasons for the relatively high number of avoidable baby and child deaths in the UK and provided recommendations for remedial action, which included all frontline health professionals involved in the acute assessment of children and young people should complete relevant professional development so are confident and competent to recognise a sick child. RCPCH resources to support clinical decision The physiology of infants and their response to sepsis is particularly difficult to identify and a different approach from adults is required. In 2020,the RCPCH supported a complete revision and update of 'Spotting the Sick Child'S,an interactive tool to support all health professionals in the assessment and recognition of the seriously ill child, RCPCH also produced free to access paediatric sepsis podcasts' designed as educational resources for all health and social care professionals exploring what sepsis is, and the complexities of recognising it_ If basic observations were performed on review of an infant outside the hospital setting within the first 10 days of life, Paediatric Early Warning Systems (PEWS) may help to identify signs outside of normal parameters and raise the level of concern: PEWS are generated by combining the scores from a selection of routine observations such as children's heart rate, respiratory rate, work of breathing; skin perfusion, conscious level etc RCPCH is currently supporting the NHS System-wide Paediatric Observations Tracking Programme? (SPOT) led by NHS England, which aims to deliver a consistent PEWS across England in both hospital and community settings. It is hoped that community use of PEWS established by NHS SPOT would provide healthcare professionals with the ability to track observations over time, https:I/www rcpch ac uk/resources/why-children-die-research-recommendations#key-messages https:Ilspottingthesickchild.com/
https:Ilwww rcpch ac uk/resources/paediatric-early-warning-system-pewsystem-developing- standardised-tool-england#how-you-can-get-involved Page 3 of' 5 they The The
such as in Brandon-Robert on days 3,5 & 8 of life, so that subtle trends or significant changes can be more easily detectable and lead to early referral and treatment. RCPCH support for parents and carers It is also important that safety netting interventions are provided to all parents and carers following discharge from hospital care after birth: In 2020, the RCPCH produced a set of posters for families in the UK about when and how to get medical help for their child: specific poster was created for parents/carers of babies less than 3 months old8 with advice on what to do if their baby is unwell and the signs and symptoms to recognise when urgent medical help is required The poster aims to provide timely and accurate advice for parents and families and to empower families to seek if their baby does not improve: They outline the different levels of concern and the appropriate urgency of medical review in a red, amber, green traffic light format All healthcare professionals are encouraged to use this guidance and familiarise themselves with the signs highlighted in the red and amber categories Disinterest in feeding and shivering are both symptoms that it advises for medical review within 24 hours: RCPCH has also raised concerns on the redeployment of health visitors during the COVID-19 pandemic9, and published a recent Insight articlel on the important role of health visitors in supporting families who have new babies in the community: We will continue to advocate for the provision of adequate resources in child health and support the wider workforce by providing open access guidance on identifying the acutely unwell child in the community: trust this provides you with the reassurance that RCPCH is working hard to support the high- quality safe care of babies in the immediate following birth across a range of areas where we can make a difference_ We welcome opportunities to work collaboratively with other organisations and professional bodies and would support the recommendations for a review of current NICE and RCOG guidelines to minimise the likelihood of recurrence of what Brandon- Robert William Collins-Hayward's family has faced. Thank you for raising this important case and reminding Us of the importance of this work.
nice@nice.org.uk Your very
Therefore, the concerns you have raised following Brandon-Roberts tragic death will be further considered by the guideline developers as part of this ongoing work We expect to publish both updated guidelines later this The NICE website will be updated with further developments Yours sincerely , Professor Chief Executive Page | 2 year:
RC Royal College of General Practitioners GP Dr Joint Flonorary Secretary Mrs Rachael Clare Griffin HM Senior Coroner For the Coroner Area of Dorset Sent by email to: March 2021 Dear Mrs Griffin, Regulation 28 Report to Prevent Future Deaths - touching on the death of Brandon-Robert William Collins-Hayward Thank you for your letter of 23 February 2021. am responding on behalf of the Royal College of General Practitioners as Joint Honorary Secretary to Council: Firstly, can convey our condolences to the family and friends of baby Brandon-Robert William Collins-Hayward: was saddened to read of Brandon's passing: The report's recommendations for better national guidance regarding the monitoring of mothers and babies following discharge after birth, and that babies are medically assessed when a mother is admitted to hospital, seem sensible but the Royal College of Midwives, the Institute of Health Visitors and the Royal Colleges of Emergency medicine and of Physicians may be in a better position to commend on these: General practitioners (GPs) usually undertake the postnatal check for mothers and babies slightly later at 6-8 weeks. Of course, patients can contact their GP earlier if they have any concerns but in terms of routine checks, earlier checks than 6-8 weeks tend to be undertaken by midwives and health visitors: trust that this reply is helpful and if you have any questions, please do not hesitate to contact me_ Yours sincerely, "llis Dr Joint Honorary Secretary of Council Royal College of General Practitioners Royal College of General Practitioners 30 Euston Square; London; NW1 2FB Tel: 020 3188 7400 info@rcgp.org.uk rcgp org.uk Patron: HRH The Duke of Edinburgh Registered Charity Number 223106
THE Royal COLLEGE OF MIDWIVES Promoting Supporting Influencing Coroner's Support Officer The Coroner's Office for the County of Dorset Bournemouth Town Hall Bournemouth BH2 6DY By Email to: 29 January 2021 Dear Re: Regulation 28 report_into the death of baby Brandon-Robert _William Collins-Hayward Thank vou for vour letter dated the 19th January outlining a request from H.M Coroner Mrs R.C Griffin, with reference to a Section 28- to prevent further death touching on the death of Brandon- Robert William Collins-Hayward: The RCM was saddened to read about the tragic death of baby Brandon. We note that the direction of the Section 28 to us was undertaken in faith by Vice President RCOG, however the RCM is a membership organisation and trade union; we have no jurisdiction over the education, employment or registration of maternity staff. The remit for the development and implementation of any new NHS guidance would sit with NHS Improvement The RCM hopes that this signposting will support the Coroners actions going forward. Please do not hesitate to make contact if the RCM can be of any further assistance. sincerely, Dr Executive Director for Services to Members The Royal College of Midwives 0300 303 0444 Open 24 hours a day; days week 10-18 Union Street +44 20 7312 3536 disability London E: info@remorg uk confident Wag pmo Stonewall SEI ISZ W: wwwrcmorg uk COMMITTED Lecilancacchmaenennn Chief Executive: President: Patron: HRH The Princess Royal; The Royal College of Midwives: coipany liited by guarantee. Registered No. 00030157 good Yours Living
iHV Institute of Health Visiting Excellence in Practice Institute of Health Visiting c/o Royal Society for Public Health, 59 Mansell St, E1 8AN 27th January 2021 Rachael Clare Griffin HM Senior Coroner for the Coroner Area of Dorset Dear Ms Griffin; Re: Regulation 28 report into the death of baby Brandon-Robert William Collins-Hayward Thank you for your email dated 19th January 2021 requesting a response to your inquest findings Your attached Regulation 28 Report contains details of the sad death of baby Brandon-Robert William Collins-Hayward in June 2019, when he was 9 days ld, with the medical cause of death recorded as Escherichia coli sepsis. In England, the midwife will be responsible for the care of the mother and infant in the immediate post-natal period. The midwife would normally discharge the mother and baby dyad from their caseload between the 10" and 14th day following the birth. At this point, the care of the dyad would be transferred to the health visiting service, although midwifery care can be extended up to 28 days after the birth if the or mother is unwell or has additional needs which require support from the midwifery team. As Brandon-Robert William Collins-Hayward sadly died 9 days after his birth, and he became unwell at home, his community care would fall within the remit of the midwifery service and GP; at this point his care would not have transferred to the health visiting service. However what you ask for is for national learning from this sad case: NICE produce national guidance used by all the relevant professionals: 'Normal Postnatal Care' covers the postnatal period for mother and baby up until 8 weeks post partum_ We note that you have already written to NICE Whilst there is a time lag with their process this would seem the most efficient way of ultimately getting the messaging out to all the relevant professionals who will base their own guidance on that produced by NICE: There is also national guidance produced by Public Health England on identifying sepsis in babies which health visitors will use to inform their practice you can find details here if you haven't already been alerted to it: https ILassets publishing service gov uk/government/uploads/system/uploadslattachment_data/file/648381/Se psis_guidance_for_health_professionals_and_school_nursespdf Paediatricians are the professional group with the greatest expertise in the care of the newborn, again note you have already written to their Royal College. However it will be GPs and midwives in the community who may make most use from guidance regarding observing the baby's health when admitting a mother with suspected sepsis before the baby is 10-14 days old and note that the RCOG have advised that Vou also writing to their colleges. We share your ambition that learning from this case should be used to prevent future deaths due to sepsis and appreciate you alerting Us. Sepsis is a life-threatening condition in young babies which is difficult to spot and can lead to a rapid deterioration in the baby'$ condition requiring urgent medical treatment: baby any
We do hope that writing to NICE will ultimately deliver the national change you require, alongside alerting the Royal Colleges of Paediatrics, Midwifery and General Practice the latter two may have their own guidance on managing sepsis in the mother (something that we don't have) which can be adjusted immediately for future care also of the infant: If you require any further information, do not hesitate to contact US, Kind regards Dr CBE Executive Director Cc Chair of the iHV
5-11 Theobalds Road XRCPCH WCOndSn Royal College of Phone: 020 7092 6000 Paediatrics and Child Health Fax: 020 7092 6001 Leading the way in Children Health WWW t rcpch ac.uk Monday, 01 February 2021 Sent by email to= Dear Coroner Rachel Clare Griffin Re: Investigation into the death of Brandon-Robert William Collins-Hayward Regulation 28 - Action to Prevent Future Deaths have carefully read your report regarding the tragic and untimely death of Brandon-Robert William Collins-Hayward and would like to first express my sincere condolences to his family. We have been provided with limited details regarding the circumstances of his death and appreciate that many ofthe details covered in the inquest were omitted for brevity_ have discussed the findings of the investigation with senior colleagues within the RCPCH: From your report we have specifically noted: On 3 of life following a normal vaginal delivery, he started to make grumbling noises, developed a shiver and reduced his milk intake: On 5 of life, he was assessed at home by the midwifery team when a visual check, but no basic observations were performed. On 8 of life, his mother was admitted to hospital with moderate to severe infection and at high risk of developing sepsis, but he was not referred for medical assessment for possible infection: On 9 of life, he was yellow in colour, had a yellow discharge in his nappy and started to struggle breathing: Cardiopulmonary resuscitation was commenced, and he arrived at hospital in a peri-arrest condition and received active treatment with continued resuscitation attempts_ It would seem from the report that Brandon-Robert developed overwhelming sepsis in a short period of time. On a clinical level, with the information provided, it seems difficult to directly link the findings on 3 and 5 of life with the tragic outcomes of this case: In infants under one month of age with sepsis, there could only be hours from the onset of abnormal observations to collapse: Occasionally there are cases of more slowly evolving infection, but with gram negative organisms such as Escherichia Coli, disease progression can be alarmingly fast. From the information provided, it appears that the potential time for intervention may have been around the hospital admission of Brandon-Robert's mother. However; the cause of sepsis in Brandon-Robert's mother that required her admission on the 6th June 2019 is not clear in the report we received, and it does not state whether the same causative organism was involved in both cases. Post-partum infection is not uncommon, and Escherichia Coli is one of many potential Page of 5 Day Day Day Day Day Day
causes The Royal College of Obstetricians and Gynaecologists' guideline 64b* only recommends treatment for the newborn if either Group A Streptococcus, Group B Streptococcus, some forms of Staphylococci, or Neisseria Meningitides are identified in the mother. Details were provided on the response the hospital Trust following this case and | recognise ~changes have been made to local policies and procedures to ensure observations of babies are taken up to 10 following birth, and babies of mothers admitted to hospital within 28 days of birth are medically reviewed either in hospital or at home by the midwifery team. You have asked the RCPCH, Royal College of Obstetricians and Gynaecologists (RCOG) and National Institute of Clinical Excellence (NICE) to review current national guidance in place for post-natal care following discharge from hospital after birth. It is advised that national guidance should be in place to perform observations on babies at each review within the first 10 days of life and medical assessment ofa baby should be required when the mother is admitted to hospital with potential sepsis within 28 of birth: National guidance recommendations Medical Royal Colleges are membership-based professional bodies, which set the standards for training of specialist doctors in some or all parts of the UK and contribute to the further development of professional medical practice As such, the RCPCH is unable to comment on specifics of the case relating to the practice of other healthcare professions and specialties beyond paediatrics. Alongside setting standards for paediatric doctors, RCPCH and affiliated specialty groups provide expert clinical input to the development of service and clinical standards. In England the most widely recognised national guidelines and standards are developed by NICE which has a rigorous and systematic process for topic selection, identifying evidence, evidence synthesis, development, consultation, and final production: Standards are developed in collaboration with expert clinical groups and stakeholders, including Medical Royal Colleges. The RCOG guideline 64b on bacterial sepsis following pregnancy was last updated in 2012. The NICE clinical guideline CG372 was last updated in February 2015 and covers the routine postnatal care women and their babies should receive for 6-8 weeks after birth: The RCPCH provided formal support for NICE quality standard 05373 that was last updated in June 2015, which describes high- quality care in priority areas for the routine postnatal care of women and their babies We support your recommendation to review these national guidelines and advise this includes: a review of the current list of organisms found in mothers that should lead to mandatory treatment of the infant: a review of current guidance on the type, frequency and formality of observational recording in new mother baby pairs: a review of potential trigger points for referral of newborns to other clinical teams. Of note, there may be significant national resource implications to completing a full set of neonatal and maternal observations on each postnatal visit. This would add around 10 minutes to each postnatal consultation for the 600,000 or so deliveries per year in England:
https:I WWw.nice org uklguidance/qs37
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We would ask that both RCOG and NICE review and update their national guidance to include these considerations. The RCPCH would be pleased to contribute to this work and provide support where appropriate NHS bodies and individual clinical departments are also expected to ensure that their operational activities comply with NICE and RCOG guidelines: We would emphasise that there should be in place in all NHS organisations clear systems and processes for clinical governance that monitor and audit practice and outcomes. These arrangements should also ensure that clinicians of all professions practice under the latest national guidance: RCPCH support for healthcare professionals am pleased to set out below additional work that has been undertaken to develop guidance in the relevant areas where RCPCH can make a difference_ This includes advocating for adequate training of all healthcare professionals reviewing children and supporting the development of resources to provide appropriate clinical decision support for healthcare professionals. In 2014,the RCPCH, British Association for Child & Adolescent Public Health and National Children's Bureau released a joint report titled 'Why Children Die"4. It examines some of the possible reasons for the relatively high number of avoidable baby and child deaths in the UK and provided recommendations for remedial action, which included all frontline health professionals involved in the acute assessment of children and young people should complete relevant professional development so are confident and competent to recognise a sick child. RCPCH resources to support clinical decision The physiology of infants and their response to sepsis is particularly difficult to identify and a different approach from adults is required. In 2020,the RCPCH supported a complete revision and update of 'Spotting the Sick Child'S,an interactive tool to support all health professionals in the assessment and recognition of the seriously ill child, RCPCH also produced free to access paediatric sepsis podcasts' designed as educational resources for all health and social care professionals exploring what sepsis is, and the complexities of recognising it_ If basic observations were performed on review of an infant outside the hospital setting within the first 10 days of life, Paediatric Early Warning Systems (PEWS) may help to identify signs outside of normal parameters and raise the level of concern: PEWS are generated by combining the scores from a selection of routine observations such as children's heart rate, respiratory rate, work of breathing; skin perfusion, conscious level etc RCPCH is currently supporting the NHS System-wide Paediatric Observations Tracking Programme? (SPOT) led by NHS England, which aims to deliver a consistent PEWS across England in both hospital and community settings. It is hoped that community use of PEWS established by NHS SPOT would provide healthcare professionals with the ability to track observations over time, https:I/www rcpch ac uk/resources/why-children-die-research-recommendations#key-messages https:Ilspottingthesickchild.com/
https:Ilwww rcpch ac uk/resources/paediatric-early-warning-system-pewsystem-developing- standardised-tool-england#how-you-can-get-involved Page 3 of' 5 they The The
such as in Brandon-Robert on days 3,5 & 8 of life, so that subtle trends or significant changes can be more easily detectable and lead to early referral and treatment. RCPCH support for parents and carers It is also important that safety netting interventions are provided to all parents and carers following discharge from hospital care after birth: In 2020, the RCPCH produced a set of posters for families in the UK about when and how to get medical help for their child: specific poster was created for parents/carers of babies less than 3 months old8 with advice on what to do if their baby is unwell and the signs and symptoms to recognise when urgent medical help is required The poster aims to provide timely and accurate advice for parents and families and to empower families to seek if their baby does not improve: They outline the different levels of concern and the appropriate urgency of medical review in a red, amber, green traffic light format All healthcare professionals are encouraged to use this guidance and familiarise themselves with the signs highlighted in the red and amber categories Disinterest in feeding and shivering are both symptoms that it advises for medical review within 24 hours: RCPCH has also raised concerns on the redeployment of health visitors during the COVID-19 pandemic9, and published a recent Insight articlel on the important role of health visitors in supporting families who have new babies in the community: We will continue to advocate for the provision of adequate resources in child health and support the wider workforce by providing open access guidance on identifying the acutely unwell child in the community: trust this provides you with the reassurance that RCPCH is working hard to support the high- quality safe care of babies in the immediate following birth across a range of areas where we can make a difference_ We welcome opportunities to work collaboratively with other organisations and professional bodies and would support the recommendations for a review of current NICE and RCOG guidelines to minimise the likelihood of recurrence of what Brandon- Robert William Collins-Hayward's family has faced. Thank you for raising this important case and reminding Us of the importance of this work.
Action Taken
NICE updated its guidance for postnatal care (NG194) to include a recommendation addressing the assessment of the baby where the mother has symptoms or signs of sepsis. The scope of its updated guidance for Neonatal infection (NG195) also covers late neonatal infection. (AI summary)
NICE updated its guidance for postnatal care (NG194) to include a recommendation addressing the assessment of the baby where the mother has symptoms or signs of sepsis. The scope of its updated guidance for Neonatal infection (NG195) also covers late neonatal infection. (AI summary)
View full response
Dear Ms Griffin, I write in reference to your correspondence, dated 1 December 2020, and our initial response given on 26 January 2021 regarding the very sad death of Brandon-Robert William Collins-Hayward. Our thoughts continue to be with his family. The concerns raised in your report surrounding the circumstances of Brandon-Robert’s death were, whether there is sufficient guidance relating to the monitoring of mothers and babies in the immediate time following discharge from hospital after birth, and the assessment of babies when the mother is admitted to hospital within 28 days of birth (especially when diagnosed with infection and at high risk of developing sepsis). At the time of our earlier response, we mentioned that our guidance in this area was being updated. Since this process has been completed, we can now confirm that our guidance for postnatal care (NG194) includes a recommendation addressing the issue of assessment of the baby where the mother has symptoms or signs of sepsis (shown here in bold):
1.2.8 For guidance on care for women with symptoms or signs of sepsis, see the NICE guideline on sepsis. If the woman has confirmed or suspected puerperal sepsis, assess the baby for symptoms or signs of infection. The scope of our updated guidance for Neonatal infection: antibiotics for prevention and treatment (NG195) also covers late neonatal infection (>72 hours to 28 days). The Royal College of Obstetricians and Gynaecologists (RCOG) have also produced guidance on the topic of bacterial sepsis following pregnancy. The purpose of this guideline
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is to provide guidance on the management of sepsis in the mother and in the baby during the puerperium (i.e. sepsis developing after birth until 6 weeks postnatally). I hope that this update is helpful.
1.2.8 For guidance on care for women with symptoms or signs of sepsis, see the NICE guideline on sepsis. If the woman has confirmed or suspected puerperal sepsis, assess the baby for symptoms or signs of infection. The scope of our updated guidance for Neonatal infection: antibiotics for prevention and treatment (NG195) also covers late neonatal infection (>72 hours to 28 days). The Royal College of Obstetricians and Gynaecologists (RCOG) have also produced guidance on the topic of bacterial sepsis following pregnancy. The purpose of this guideline
Page | 2
is to provide guidance on the management of sepsis in the mother and in the baby during the puerperium (i.e. sepsis developing after birth until 6 weeks postnatally). I hope that this update is helpful.
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56-Day Deadline
25 May 2021
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Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 18th June 2019 I commenced an investigation into the death of Brandon-Robert William Collins-Hayward.
The investigation concluded at the end of the inquest on the 19th November 2020.
The medical cause of death was:
1a Escherichia coli sepsis
The conclusion of the inquest was Natural Causes.
The investigation concluded at the end of the inquest on the 19th November 2020.
The medical cause of death was:
1a Escherichia coli sepsis
The conclusion of the inquest was Natural Causes.
Circumstances of the Death
The deceased was born on the 29th May 2019 following a normal vaginal delivery and presented as a healthy baby boy. When he was 3 days old, he started to reduce his milk intake, developed a shiver of his lip and started to make grumbling noises. Other than that, he displayed no other symptoms until 10.30am on the 7th June 2019 when he was noted to be yellow in colour, had a yellow flemish discharge in his nappy and started to struggle breathing. The emergency services were called and during that call he stopped breathing. Cardio Pulmonary Resuscitation was commenced and he was taken to Poole Hospital, Poole. On arrival he was in a peri-arrest condition and despite continued resuscitation attempts and active treatment his condition did not improve, and he died later that day. Of note his mother was admitted to Poole Hospital on the evening of the 6th June 2019 with moderate to severe infection and deemed to be a high risk of developing sepsis.
Copies Sent To
Robert
University Hospital Dorset NHS Foundation Trust
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.