Dear Ms Marsh Regulation 28; Report to Prevent Future Deaths, concerns arising out of evidence heard at the Inquest into the death of Ezra James Boulton Following the inquest into the death of Ezra James Boulton, which was concluded on 21st June, you issued a regulation 28 report addressed to myself and the Director of Midwifery ad Maternity at Portsmouth Hospitals NHS Trust (PHT) , us t0 respond to a list of 4 concerns. Those concerns have been taken from your report dated 1st July 2019 and are listed below followed in each case by our answers on behalf of Portsmouth Hospitals NHS Trust (PHT). (1) At Ezra'$ Inquest was told in evidence that throughout her pregnancy (this being her first pregnancy) (Ezra'$ mother) did not see the same midwife twice. believe that there should be some Ievel of continuity of care in antenatal appointments to ensure that all of the necessary checks are preformed and appropriate antenatal advice is shared with the mother, Nice Guidance "Antenatal care for uncomplicated pregnancies" CG62 sets out at Appendix D a schedule of appointments which should be provided for women with uncomplicated pregnancies. The requirement is for 10 appointments for nulliparous women and for parous women The schedule sets out in detail which checks and advice should be provided at each of the appointments. Each patient has their own hand held notes which are retained by them ad brought to every antenatal appointment: As such each healthcare professional who meets a woman will have access to all the information they need to enable them t ensure that all necessary checks are performed and appropriate advice is shared with them "Better Births: Improving outcomes of maternity services in England A Five Year Forward for maternity care" (Better Births) published by NHS England in 2016 sets out a number of key recommendations for improvement in maternity care. This includes a move towards personalised care the aim of woman having her own midwife, who is part of a small team of midwives, based in te community, who can provide continuity throughout her pregnancy. Annex B of the "NHS Operational Planning and Contracting Guidance 2019/20" (NHSE) has set a national aspiration to increase the number of women receiving continuity of the person caring for them pregnancy, birth and postnatally so that by March 2020, 35% of women will be booked onto continuity %f carer pathway, PHT is 0n track to achieve the target of 35% of women being booked on the pathway by March 2020. asking View and every during

As a first step towards achieving this, PHT is setting up 2 continuity of carer pathway teams, of 6-8 community midwives, with each midwife a caseload of approximately 40 women. This will enable these women to have a named midwife and a "buddy" who will coordinate care throughout Ihe antenatal, birth ad postnatal period, The first team will be in place by the end of August with the second team being established towards the end of 2019, Those patients who have more complex pregnancy needs such as those with diabetes ad multiple birth pregnancies already receive continuity of care because have their antenatal appointments carried out in the hospital environment with a small team of specialised staff, (2) also heard that own personal pregnancy was uneventful but am concerned that the distinct lack of continuity of care appears to expose a risk that should there be any abnormalities andlor risk factors to either mother or baby as the pregnancy develops, that ihese have the potential to be missed; either entirely missed or not properly communicated t0 whichever midwife conducts the next antenatal appointment; causing significant risk to both mother ad baby; believe that there is a serious risk of future death posed by this lack of continuity of care. As stated above, PHT is striving to achieve the model of continuity of care for women set out in Better Births, the aim of which is t provide hands on care for the woman and her baby with greater coordination and the development of a relationship between the woman and the midwife for her and her baby: There is already in place a well established process which seeks to ensure that abnormalities ad risks are picked up pregnancy: Each woman has her own handheld notes which are taken to antenatal appointment and all checks and assessments are recorded in them. This information is therefore available to every healthcare professional caring for the woman during the course of her pregnancy: The NICE guidance referred to in answer t0 concern above sets out in detail the appropriate checks for assessment for each antenatal appointment depending o the stage of the pregnancy. midwife employed by PHT is very familiar with the format of the notes and the checks and assessments required at each stage of ine pregnancy: are expert practitioners in nommal pregnancy and birth ad are trained to pick Up any deviation from normal and escalate as appropriate_ Women are also given details of the maternity assessment unit at PHT which can contact for support and advice if they are concerned about the progress of their pregnancy and if needed will then be asked to attend hospital for clinical assessment, (3) At Ezra's inquest was told that as baby had been delivered safely with no significant injuries to mum (i.e. no significant tearing or blood loss) that the family were encouraged to leave rapidly . On discharge, the focus of information sharing and care was distinctly focused on after: care for the mother: The family did not recall being given any information directly on safe- sleeping; either at antenatal appointments or at a post-natal stage from any midwife or Health Visitor. information were given was provided almost as an after-thought and given in the form of a leaflet which it was suggested that read: was told that the first HV appointment the family received was approximately seven weeks after Ezra had been born; believe that making Safe sleeping information readily available to all parents at an early stage may significantly reduce the risk of future infant deaths due to co-sleeping: PHT has a discharge checklist sticker which is placed in the woman's medical records following birth and includes "safe sleeping" and must be ticked by the midwife on discharge to confirm that the woman has been advised aboul safe sleeping: There is also a safe sleeping leaflet which is usually given to women 0 discharge as part of a package of advice leaflets . However; The Hampshire Safeguarding Children's Board is currently reviewing the Safe Sleeping Leaflet with a view to producing a more engaging version that raises the of this important issue_ having they caring during every Every They they they fairly Any they they " profile

In the meantime; on discharge after birlh, PHT midwives are giving women a separate photocopy of page 9 of the Child Health Record (red book) which conlains advice about safe sleeping as well as details of the Lullaby Trust and NHS Choices where further advice can be obtained. This handheld book Is normally given to women by their health visitor and not PHT midwives , Generally speaking the post natal care of women is handed over to Ihe Health Visitor Service at around 10 post birth , which is extended to up to 28 where the woman has additional need for midwifery support The Heallh Visitor Service is provided by Solent NHS Trust and am therefore unable to provide any further information about those visits_ (4) also heard that midwives are unaware that causing the death of an infant due to co-sleeping becomes an automatic criminal offence of "overlay" (under section 1(2) of the Children and Person's Act 1933) if alcohol andlor drugs are involved: believe that making this information readily available to midwifery practitioners may reduce the risk of future infant deaths due to co sleeping but may also reduce the need for Police involvement (with a view to prosecution) in what Is already a tragic time for a family who have lost their child. We recognise the importance of ensuring that midwifery staff are familiar with the components of the criminal offence of "overlay" ad in response to your comments the Director of Midwifery and Matemity has emailed all midwives and neonatal nursing, medical and support staff to alert Ihem to tat definition; With regard to your concers about Police involvement; the "Sudden unexpected death in infancy and childhood Multi agency guidelines for care and investigation" published in November 2016 sets out guidelines on the multi-agency approach t0 investigating unexpected deaths in childhood and and includes a requirement at paragraph 2.4 that the "Police should be contacted as soon as possible after the arrival of the infant in the emergency department;, if this has not already been done;" In those circumstances it is impossible to avoid Police involvement However the guidelines also stress the importance of ensuring that Ihese situations are handled with sensitivity for the grieving family, which is of course always primary consideration for (his organisation, hope that this response provides you with the reassurance you require that the issues you have raised are already priorities for the Trust but please do not hesitate to contact me if you require further clarification on any of the information provided