Bridget Marie Connell-Graham
PFD Report
All Responded
Ref: 2018-0297
All 1 response received
· Deadline: 16 Mar 2019
Coroner's Concerns (AI summary)
The lack of a clear national definition for 'cervical trauma' leads to inconsistent approaches in investigating prior history and planning clinical treatment during pregnancy, risking premature births.
View full coroner's concerns
_ The inquest heard that at a scan performed on 31st January 2018 after an attendance the previous with an episode of bleeding Bridgets mother was found to have a shortened cervix On 1st February she was bom day -
prematurely: A history of cervical trauma was contained within the maternal notes. The inquest heard that whilst there is guidance from NICE as to the appropriate action to be taken where there is a history of cervical trauma there is no clear definition of what amounts to cervical trauma: The inquest was told that this means there is an inconsistent approach nationally as to what will be treated as a of cervical trauma and therefore in what steps are taken in relation to investigating a previous history of cervical trauma and planning clinical treatment during pregnancy: ACTION SHOULD BE TAKEN In opinion; action should be taken to prevent future deaths and | believe you have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 22nd November 2018. |, the coroner; may extend the Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.
prematurely: A history of cervical trauma was contained within the maternal notes. The inquest heard that whilst there is guidance from NICE as to the appropriate action to be taken where there is a history of cervical trauma there is no clear definition of what amounts to cervical trauma: The inquest was told that this means there is an inconsistent approach nationally as to what will be treated as a of cervical trauma and therefore in what steps are taken in relation to investigating a previous history of cervical trauma and planning clinical treatment during pregnancy: ACTION SHOULD BE TAKEN In opinion; action should be taken to prevent future deaths and | believe you have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 22nd November 2018. |, the coroner; may extend the Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.
Responses
Action Planned
NICE will add the definition of 'cervical trauma' to the 'Terms used in this guideline' section of the Preterm labour and birth (NG25) guideline to improve accessibility. (AI summary)
NICE will add the definition of 'cervical trauma' to the 'Terms used in this guideline' section of the Preterm labour and birth (NG25) guideline to improve accessibility. (AI summary)
View full response
Fom Jackie Doyle-Price MP Department Parliamanlary Undar Secrelary or Stale for Menlal Health, Inequalilles and Suicide Prevenlon of Health & Social Care 39 Victoria Street London Sw1h OEU 020 7210 4850 Your Ref: 9480/CLB PFD-[150539 Ms Alison Patricia Mutch HM Coroner's Court 1 Mount Tabor Street Stockport SKI 3AG K (9" November 2018 Da Mutay Thank you for your correspondence of 26 September to Matt Hancock about the death of baby Bridget Marie Connell-Graham; Iam replying as Minister with portfolio responsibility for maternity care. Ihave noted carefully the matter of concern in your report. It is essential that we look to make improvements where we can to ensure the safety of healthcare services and prevent future deaths and [ am grateful to you for bringing these matters to my attention. My officials have made enquiries with the National Institute for Health and Care Excellence (NICE): Iam advised that the guideline, Preterm labour and birth (NG2S)' , includes a 'Terms to use in the guideline' section (at the end of Recommendations) that contains definitions This currently does not include & definition of cervical trauma However; the full guideline document for NG2S does. The full guideline document contains the recommendations, the evidence they are based on and considerations of the guideline developers It also contains & glossary which defines cervical trauma as 'Physical injury to the cervix including surgery; for example, previous cone biopsy (cold knife or laser), large - excision of the transformation zone (LLETZ) any number) or radical diathermy" hltps: wunice QIg uklguidance ng25 key loop
NICE has advised that it will ensure this definition is added t0 the 'Terms used in this guideline' section as soon as possible, so it is easily accessible to those looking over the recommendations: I hope this response is helpful: JACKIE DOYLE-PRICE (Jcka
NICE has advised that it will ensure this definition is added t0 the 'Terms used in this guideline' section as soon as possible, so it is easily accessible to those looking over the recommendations: I hope this response is helpful: JACKIE DOYLE-PRICE (Jcka
Sent To
- Department for Health
Response Status
Linked responses
1 of 1
56-Day Deadline
16 Mar 2019
All responses received
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.