Alba Pemberton
PFD Report
All Responded
Ref: 2018-0288
All 1 response received
· Deadline: 15 Mar 2019
Coroner's Concerns (AI summary)
Protocols for meconium classification and equipment use are inadequate, and there's insufficient obstetric review and multidisciplinary collaboration in birthing centres and low-risk maternity cases.
View full coroner's concerns
The presence of meconium should be classified as meconium, and not graded, and once present should result in the use of CCG equipment. That every patient at a birthing centre should be the subject of obstetric review North London Coroners Court, 29 Wood Street, Barnet EN5 4BE Clerk to H.M. Senior Coroner court.clerk@hmc-northlondon.co.uk
Her Majesty’s Coroner for the Northern District of Greater London (Harrow, Brent, Barnet, Haringey and Enfield) That obstetricians should be more involved in the management of low risk cases There should be MDT meetings with the obstetric staff and midwifery staff and obstetric staff encouraged to work closely together in the management of low risk cases.
Her Majesty’s Coroner for the Northern District of Greater London (Harrow, Brent, Barnet, Haringey and Enfield) That obstetricians should be more involved in the management of low risk cases There should be MDT meetings with the obstetric staff and midwifery staff and obstetric staff encouraged to work closely together in the management of low risk cases.
Responses
Noted
The Department of Health and Social Care references NICE guidelines on intrapartum care and states NICE will log the coroner's concerns for future review but does not plan to update the guideline at this time. (AI summary)
The Department of Health and Social Care references NICE guidelines on intrapartum care and states NICE will log the coroner's concerns for future review but does not plan to update the guideline at this time. (AI summary)
View full response
From Jackie Doyle-Price MP Parliamentary Under Secretary of State for Mental Health, Department Inequalities and Suicide Prevention of Health & Social Care 39 Victoria Street London SwIh OEU 020 7210 4850 PFD-1148325 Mr Andrew Walker HM Coroners Court 29 Wood Street Barnet ENS 4BE November 2018 De 4 A Jcll& Iam writing further to the Regulation 28 Prevention of Future Deaths Report issued on 10 September following the inquest into the death of baby Alba Pemberton: Iam replying as Minister with portfolio responsibility for maternity care. My officials have made enquiries with the National Institute for Health and Care Excellence (NICE) and NHS Improvement on the matters of concern in your report: In 2014, NICE published clinical guideline (CG190), Intrapartum care for healthy women and babies' , which sets out clear recommendations relating to risk assessment and place of birth. CG190 is evidence-based, using research results from a number of studies, including the Birthplace Study, 20112, which provides robust data on the risks and benefits of each birth setting that healthcare professionals and women can use to make informed choices on the place of birth: CG190 does not recommend an obstetric review or that obstetricians should be more involved in low risk births https: !LWwwnice Org uklguidance cgl9 https: www npel OX IC ukbinthplace May
Involving obstetricians in the midwifery-led care of women in a birth centre would undermine the woman's choice for low-risk care and the midwife' s role as the lead for a normal birth: Rather than obstetricians routinely involved in the care of women assessed as at low-risk of complications, CG190 sets out clear recommendations relating to risk assessment and place of birth: There should be protocols in place locally regarding risk assessment, consultation with, and escalation obstetric care: It appears, from the inforation given, that the failings in this case related to a lack of ongoing clinical assessment and escalation once there were signs and symptoms of fetal distress. You indicate in report that five-minute monitoring of the fetal heart rate was not followed by the healthcare professionals in the second stage f labour: As you will be aware, CG190, gives clear recommendations on the level of observations in the second stage of labour and the need to assess whether transfer of care may be needed: 'Observations during the second stage: 1.13.2: Perform intermittent auscultation of the fetal heart rate immediately after a contraction for at least minute, at least every 5 minutes With regard to meconium, CG190 defines the presence of meconium-stained liquor as either 'non-significant' or 'significant' : 'Non-significant meconium is_ green or yellow amniotic fluid that is thin and with no lumps of meconium present. It is sometimes referred to as 'light' or 'thin meconium: Significant meconium is dark green or black amniotic fluid that is thick or tenacious or any meconium-stained amniotic fluid containing of meconium. It is sometimes referred to as 'heavy or 'thick' meconium The NICE guideline includes the following recommendations regarding documenting the presence or absence of 'significant meconium:
1.5.2 As part of ongoing assessment; document the presence or absence of significant meconium. This is defined aS dark green or black amniotic fluid that is thick or tenacious, or any meconium-stained amniotic fluid containing lumps of meconium being being to, your pale lumps
'1.5.3 If significant meconium is present, ensure that: healthcare professionals trained in fetal blood sampling are available during labour and healthcare professionals trained in advanced neonatal life support are readily available for the birth '1.5.4 If significant meconium is present, transfer the woman to obstetric-led care provided that it is safe to do sO and the birth is unlikely to occur before transfer is completed. Follow the general principles for transfer of care described in section
1.6 NICE has advised that it considers that CG190 appropriately reflects the available evidence and does not need to be at this time: Iam content to accept that position: You will wish to note that NICE will the concerns in your report against this guideline topic so that can be taken into consideration when NICE next comes to review the need for the guideline to be updated. JACKIE DOYLE-PRICE updated log they JJo
Involving obstetricians in the midwifery-led care of women in a birth centre would undermine the woman's choice for low-risk care and the midwife' s role as the lead for a normal birth: Rather than obstetricians routinely involved in the care of women assessed as at low-risk of complications, CG190 sets out clear recommendations relating to risk assessment and place of birth: There should be protocols in place locally regarding risk assessment, consultation with, and escalation obstetric care: It appears, from the inforation given, that the failings in this case related to a lack of ongoing clinical assessment and escalation once there were signs and symptoms of fetal distress. You indicate in report that five-minute monitoring of the fetal heart rate was not followed by the healthcare professionals in the second stage f labour: As you will be aware, CG190, gives clear recommendations on the level of observations in the second stage of labour and the need to assess whether transfer of care may be needed: 'Observations during the second stage: 1.13.2: Perform intermittent auscultation of the fetal heart rate immediately after a contraction for at least minute, at least every 5 minutes With regard to meconium, CG190 defines the presence of meconium-stained liquor as either 'non-significant' or 'significant' : 'Non-significant meconium is_ green or yellow amniotic fluid that is thin and with no lumps of meconium present. It is sometimes referred to as 'light' or 'thin meconium: Significant meconium is dark green or black amniotic fluid that is thick or tenacious or any meconium-stained amniotic fluid containing of meconium. It is sometimes referred to as 'heavy or 'thick' meconium The NICE guideline includes the following recommendations regarding documenting the presence or absence of 'significant meconium:
1.5.2 As part of ongoing assessment; document the presence or absence of significant meconium. This is defined aS dark green or black amniotic fluid that is thick or tenacious, or any meconium-stained amniotic fluid containing lumps of meconium being being to, your pale lumps
'1.5.3 If significant meconium is present, ensure that: healthcare professionals trained in fetal blood sampling are available during labour and healthcare professionals trained in advanced neonatal life support are readily available for the birth '1.5.4 If significant meconium is present, transfer the woman to obstetric-led care provided that it is safe to do sO and the birth is unlikely to occur before transfer is completed. Follow the general principles for transfer of care described in section
1.6 NICE has advised that it considers that CG190 appropriately reflects the available evidence and does not need to be at this time: Iam content to accept that position: You will wish to note that NICE will the concerns in your report against this guideline topic so that can be taken into consideration when NICE next comes to review the need for the guideline to be updated. JACKIE DOYLE-PRICE updated log they JJo
Sent To
- Department of Health and Social Care
Response Status
Linked responses
1 of 1
56-Day Deadline
15 Mar 2019
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On the 12th March 2018 I opened an inquest touching the death of Alba May Pemberton , 2 days old. The inquest concluded on the 12th June 2018. The conclusion of the inquest was “Consequences of complications during the second stage in childbirth.”, the medical case of death was 1a Hypoxia, 1(b) Ischaemic Encephalopathy.
Circumstances of the Death
On the Tenth of August 2016 Alba was born having suffered a period of hypoxia during the active stage of the second stage of the delivery. It is likely that by 21.45 hrs on the Ninth of August the active second stage had begun and that auscultation of the heart should have taken place every 5 minutes, this level of monitoring did not start until 23.12, This period had a bearing on Alba's death in that there is a possibility that 5 minute monitoring would have lead to the discovery of hypoxia at an earlier stage. If a CTG equipment had been used the trace is likely to have been abnormal for a considerable period and earlier delivery is likely to have resulted in Alba surviving. Alba was born seriously unwell as a consequence of the hypoxia and had only two days of life
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.