UK Inquiry Tracker

Billy Wilson

PFD Report All Responded Ref: 2017-0061

Date of Report 9 March 2017

Coroner David Hinchliff

Coroner Area West Yorkshire (East)

Response Deadline est. 4 May 2017

Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths

Judiciary.uk Report PDF

All 1 response received · Deadline: 4 May 2017

Coroner's Concerns (AI summary)

Critical gaps exist in mandatory and assessed training for CTG tracing interpretation for both student and practicing midwives, leading to proficiency issues upon hospital recruitment.

View full coroner's concerns

In the circumstances it is my statutory duty t0 report to you: (1) request that you ensure that training on CTG tracing interpretation Is contained in the Undergraduate Syllabus for all Midwifery Degree Courses throughout the country (2) That this is compulsory and that it has to be assessed on a pass or fail basis, and that a student Midwife cannot seek registration until this vital element in training is undertaken: (3) That Hospital Trusts should not recruit newly qualified Midwives until can demonstrate their understanding and proficiency in CTG tracing interpretation: (4) There should be formal refresher training for all practising Midwives in CTG tracing and interpretation done on a yearly basis, and that this should be assessed on a pass or fail basis, and not merely left to the responsibility of the individual Midwife t0 complete an E-learning package without Management Review and assessment_

Responses

Royal College of Obstetricians and Gynaecologists Education

17 Mar 2017

Noted
The Royal College of Obstetricians & Gynaecologists acknowledges the concerns regarding CTG training. They note CTG training is part of the current curriculum and offer support for further proposal. (AI summary)

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Dear Mr Hinchcliff Your ref: DH/ST/893/15 re Baby Karpovich DH/KLA/3156/13 re Billy Wilson Thank vou for writing to me on 22 February and & March 2017 regarding the inquest of the deaths of Maxim Karpovich and Billy Wilson_ responded t on 17 March 2017 after meeting discussing with the RCOG Officers and seeking input and advice from the new Vice Presidents of Education and Clinical Quality: apologised to_ ifor the delay in my response explaining that needed to consult with the Curriculum Review team in some detail before address his concerns appropriately: The consensus from the RCOG Officers and the Curriculum Review team was that a theoretical course in itself _ particularly a course taking place over many weeks a5 was suggested ~was unrealistic for ail trainees, many of whom are struggling to obtain study leave from their Trusts and are also complaining bitterly about the mandatory training modules that they are expected to complete: There is also the question of whether a course is the most appropriate method of training as the problems that can arise in clinical practice are generally when the whole picture is not considered and the issue is not escalated appropriately: Cardiotocograph (CTG) training Is part of the current RCOG curriculum: In summary it is part of module 10 'Management of labour' and by the end of Specialist Training year 1 (ST1), all trainees must produce evidence of having completed a course demonstrating CTG interpretation skills (see Module 10 attached with relevant sections highlighted) before they can progress to become an ST2_ As you will see this is usually an e-learning course and the resources which most trainees use are either the KZMS" PTP (Perinatal Training Program) package or the e-learing for Healthcare Electronic Fetal Monitoring chapter: You may be aware that the K2 training requires hospitals to have a site licence and trainees can then be registered: The e-learning for Healthcare requires doctors to have a NHS email address and then they can register for free; but this precludes those working out with the NHS. However should mention here that, as the official host, the RCOG has put a significant amount of resource into supporting the eFM package, working with the Roval College of Midwives and Health Education England. Royal of Obstetricians and Gynaecologists 27 Sussex Place; Regents Park London NWI 4RG Telephone: +44 (0J20 7772 6200 Facsimile: +44 (0)20 7723 0575 Website: wwwrcogorguk Registered chanty no, 2/3280 May ` and could being College "

Royal College of Obstetricians & Gynaecologists CTG training is additionally included in the basic practical skills course which all trainees have to take to progress to ST3. One ofthe 10 practical stations is on interpretation of CTG and fetal blood sampling: All delegates are expected to complete the on-line tutorials in electronic fetal monitoring and fetal blood sampling during the pre-course preparation and should basic understanding the fetal monitoring principles_ In terms of the new curriculum; the pressure of completing modules does not allow us to increase the emphasis on CTG interpretation but it will remain an important that trainees evidence this skill; The RCOG opinion on CTG interpretation is that the problems arise in clinical practice when the whole picture is not considered, and this is why trainees are encouraged to demonstrate clinical competence within teams as part of workplace based assessments. In addition senior trainees who are likely to be in of such teams can register for our Advanced Training Skills Module (ATSM) in advanced antenatal practice or advanced labour ward practice, both of which contain curricula that deliver additional training in the teamwork around CTG interpretation which includes the running of team meetings and reviews of decision making Further details of our ATSM programme can be found at https LLWWW rcg org uklen/careers-training/specialty-training-curriculumlatsmsl: Whilst we fully understand the concerns around this case we would like to reassure you that the College is committed to ensure that safety is at the heart of anything we do. We have discussed whether one additional course such as that proposed by Professor Steer for all our trainees would enhance safety We believe that it would not and that we should therefore concentrate on ensuring consistency of our curriculum and also engaging with NHS England and the 'Safer Maternity Care' programme; launched by Jeremy Hunt at the RCOG in October 2016. This important national programme has come with a very strong bias towards team work and leadership, supported by a new funding stream for multi-professional training programmes. As am sure you are aware; the Secretary of State announced E8m of funding for maternity safety training last Autumn 2016, with at least E4Ok to each NHS Trust In England: This has allowed some units to fund training in subjects such as team working in intrapartum care and CTG interpretation via courses that have already been established: Lastly should mention that in my reply tol reminded him that the RCOG currently offer an "intrapartum fetal surveillance course" which is run over one at the RCOG and is aimed at obstetric team working: suggested to that he could Iiaise with our Convenor of Meetings to help us design a pilot programme alng the lines that Professor Steer proposes, that have charge fully day -

Royal College of Obstetricians & Gynaecologists could then be trialled at the RCOG: offered to give this my full support if he wished to pursue the proposal and believe that he has already started to do so Ifyou would like to discuss this further with me please do not hesitate to contact me

Sent To

Nursing and Midwifery Council

Response Status

Linked responses 1 of 1

56-Day Deadline 4 May 2017

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 5th December 2013 commenced an investigation into the death of Billy Wilson; 3 days old. The investigation concluded at the end of the Inquest on 15 March 2017 . The conclusion of the Inquest was that the cause of death was 1(a) Hypoxic-ischaemic brain injury 1(b) Perinatal asphyxia and a Narrative Conclusion was recorded, a copy of which is attached hereto.

Circumstances of the Death

Billy Wilson was a baby born at 0250 hours on 27th November 2013 at Pinderfields Hospital; Wakefield. He survived for 3 days and his death was confirmed on the Paediatric Neonatal Unit at Leeds General Infirmary at 0140 hours on 30th November 2013. The cause of death is as stated above. This was a high risk pregnancy as it was suspected that Billy's mother suffered with polyhydramnios and that Billy was thought to be a large baby. The mother was admitted t0 Pinderfields Hospital on 21st November 2013 for inducement of labour She was given a prostaglandin pessary which had little effect This was repeated on the 22nd November 2013 and a third such pessary was given on the November 2013. Furthermore a prostin gel was used on 25th November 2013, all of which were without gain: The mother's uterine contractions and the baby's heart rate were monitored with a cardiotocograph (CTG): On one occasion the intermittent CTG tracing showed contractions t0 be 6 or 7 in 10 minutes hyperstimulation: Notwithstanding this the mother was started on an oxytocin drip, the dose of which was steadily increased, which obviously increased and strengthened the frequency of the contractions In Billy's case the monitoring of the CTG on 26th November 2013 showed an abnormality, which should have caused the syntocinon to be stopped: From 1740 hours onwards an expert review identified significant failings in care by both Midwives and Obstetricians, notwithstanding repeated irregularities in both the frequency of contractions and the foetal heart rate, yet the syntocinon was continued and on occasions was increased. Billy suffered from excessive stress and periods of hypoxia caused by the hyperstimulation and the fact that the labour was not progressing. The syntocinon should have been stopped. At 2000 hours the care of the mother was allocated to a newy qualified Midwife This was only her first night shift and boy 23r onlly her sixth shift since qualifying in September 2013. This Midwife was not able to interpret the CTG printout as being pathological and she increased the syntocinon: When it was finally realised that the baby was in distress and likely to be brain damaged he was delivered by forceps, in a poor state_ He was resuscitated and then transferred to the Neonatal Paediatric Intensive Care Unit at Leeds General Infirmary where, despite all efforts, he deteriorated and his death was confirmed at 0140 hours on 30h November 2013. The newly qualified Midwife referred to in her evidence stated that she had not received appropriate instruction or training during her Midwifery Course at Bradford University and that when she became registered and took up her first appointment she had not completed the second part of an E-learning programme on the interpretation of CTG traces. An expert witness on Midwifery issues stated that this is commonplace and that student Midwives can qualify and become registered without this essential training:

Action Should Be Taken

In my opinion action should be taken t0 prevent future deaths and believe you and your organisation have the power to take such action: