Dear Madam,

Response to Regulation 28 Prevention of Future Deaths Report – Malyun KARAMA I have set out within this letter and in the action plan and documents attached, the Trust’s responses to the Matters of Concern that you have brought to our attention in your Regulation 28 Prevention of Future Deaths Report dated 21 August 2020. I have been assisted in compiling the Trust’s responses by:

 Dr , Clinical Director of Obstetrics and Gynaecology  , Head of Midwifery  Dr , Consultant Obstetrician & Service Line Lead for Obstetrics  , Head of Quality Governance

I have set out below each of the Matters of Concern followed by the Trust’s responses:

1. Evidence was heard at the inquest of changes in systems at the Royal Free Hospital following the events of 20 February 2020, including changing the misoprostol dose protocol and making a medical review mandatory before each administration to a multi gravida mother. However, the Royal Free had not yet taken any steps to ensure that there was learning at a national level of the increased risk of rupture in a multi gravida mother. The more widely known increased risk is simply in vaginal birth after caesarean.

2. Evidence was heard at the inquest that there was no computer in the delivery suite and so the midwife could not record her observations contemporaneously or without leaving the room which was found to be sub-optimal.

1. Learning at a national level of the increased risk of rupture in a multi gravida mother

Please refer to the attached action plan item (1d) and documents, which can be summarised as follows:

The Actions required are:

 For the case to be presented at the NCL (North Central London) Local Maternity System Quality and Safety Meeting. This is set to take place on 6 November 2020.

 Learning in relation to the increased risk of rupture in relation to multigravida women to be shared with the national maternity risk/governance managers email distribution forum. This was completed on 2 October 2020 and the email that was distributed has been embedded into the attached action plan.

 Learning from the incident to be shared with the Project Manager for the Maternity Clinical Network – NHS England and NHS Improvement – London Region. This was completed on 2 October 2020 and the email that was distributed has been embedded into the attached action plan.

2. Ensure a computer is in the delivery suite to enable contemporaneous note-keeping

Please refer to the attached action plan item 2 and document, which can be summarised as follows:

The Action required is for a review to take place of the workstations on wheels (WOW) on the Labour Ward to ensure that all Labour rooms possess a computer for staff use.

This review was completed on 2 September 2020 and it identified that there were the appropriate number of workstation on wheels for the Labour rooms. However it was identified that staff were removing the Wow carts from the Labour rooms. This gave rise to recommendations being sent out via email on 2 September 2020 that:

1. The Wow carts should not be removed from the delivery room;
2. If the Wow carts are not working, the staff member: should
- speak to the labour ward co-ordinator in order to check this and to check that the cables are correctly placed;
- reported it to the IT helpdesk.
- Log an incident on our Datix system to ensure the issue is investigated.

Thank you for bringing these matters to the Trust’s attention and providing us with an opportunity to further review and improve our processes. The Trust is continuously seeking to improve the quality and safety of the care that it provides to its patients and your Preventing Future Deaths Report has been a helpful contribution to this ongoing and extremely important process.