Owen Widlake
PFD Report
Historic (No Identified Response)
Coroner's Concerns (AI summary)
Inadequate staffing and training for NICU staff, particularly in escalating concerns and recognizing respiratory distress, compounded by unclear roles, poor observation recording, and deficient handover systems.
View full coroner's concerns
In the circumstances it is my statutory to report to you. (1a) Staffing levels over the weekend and bank holiday, in particular the use of ANNP and SANNP trained staff to replace junior and registrar level doctors on duty covering NICU. (1b) The need for a dedicated junior level doctor or registrar to be on duty 24 hours covering NICU, and not a limited 3 4 hour shift. (1c) The need to clarify as to the role an ANNP or SANNP has, whether in & nursing capacity or medical capacity, and how they are perceived by other staff
2) The observations for children in transition or admitted to NICU are not recorded seamlessly nor are easily viewable whether on a chart or graph.
3) The nursing staff do not appear able to escalate concerns either i) due to lack of clear care plans and escalation markers poor training_particularly the SANNP and ANNP in the recognition of respiratorydistress Coroner's Officc, Castle Hill, The Castle; Winchester, S023 SUL Tel 01962-667884 Fax 01962-667893 end and The duty and PPHN iii) a lack of empowerment indicating a lack of leadership
4) The on going training undertaken of nursing staff in relation to PPHN and respiratory distress has been the responsibility of SANNP land a consultant, with no indication that they have undertaken training themselves
5) Concern as to staff deciding whether a child in respiratory distress should be NBM or not and what is the guidance on this
6) The Transfer policy for this Trust and what would be guidance or indicators a to the seeking of tertiary level assistance and transfer, especially when a crisis point may be reached past 1Opm_ What is the current system in place for handovers between medical staff and nursing staff whether written or verbal, and what information must be included as part of that handover.
2) The observations for children in transition or admitted to NICU are not recorded seamlessly nor are easily viewable whether on a chart or graph.
3) The nursing staff do not appear able to escalate concerns either i) due to lack of clear care plans and escalation markers poor training_particularly the SANNP and ANNP in the recognition of respiratorydistress Coroner's Officc, Castle Hill, The Castle; Winchester, S023 SUL Tel 01962-667884 Fax 01962-667893 end and The duty and PPHN iii) a lack of empowerment indicating a lack of leadership
4) The on going training undertaken of nursing staff in relation to PPHN and respiratory distress has been the responsibility of SANNP land a consultant, with no indication that they have undertaken training themselves
5) Concern as to staff deciding whether a child in respiratory distress should be NBM or not and what is the guidance on this
6) The Transfer policy for this Trust and what would be guidance or indicators a to the seeking of tertiary level assistance and transfer, especially when a crisis point may be reached past 1Opm_ What is the current system in place for handovers between medical staff and nursing staff whether written or verbal, and what information must be included as part of that handover.
Sent To
- Isle Of Wight NHS Trust
Response Status
Linked responses
0 of 1
56-Day Deadline
22 Jan 2018
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Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 03/06/2016 commenced an investigation into the death of Owen Richard Widlake_ The investigation concluded at the of the inquest on 17 November 2017 that Owen Widlake died of natural causes as a result of undiagnosed PPHN. It is not possible to say on the balance of probabilities whether Owen would have survived if his significant respiratory distress had been recognised, investigated and treated at the time. The cause of death was found to be 1a) Acute Intraventricular Haemorrhage 1b) Persistent Pulmonary Hypertension of the Newborn Meconium Aspiration.
Circumstances of the Death
Owen Widlake was born on the 3Oth May 2016 at St Mary's Hospital, Isle of Wight full term and healthy, but had aspirated meconium. He was placed in ambient oxygen and continued to need oxygen at ever increasing levels failure of his respiratory function was recognised in part; though the severity was not: Transfer to a tertiary specialist neonatal unit was not sought early enough particularly considering the geographical location at St Mary's He was diagnosed at late stage with PPHN and as this was untreated it could not be resolved. He suffered an acute intraventricular haemorrhage which on the balance of probabilities was a result of the PPHN. He died at Southampton General Hospital on the 31st May 2016_
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you, the Isle Of Wight NHS Trust; have the power to take such action:
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.