Vasilis Ktorakis
PFD Report
All Responded
Ref: 2015-0377
All 1 response received
· Deadline: 14 Dec 2015
Coroner's Concerns (AI summary)
The report identifies errors in care, including a delay in starting Syntocinon, inadequate recording of a management plan, an error of judgement in allowing passive descent, and a systemic issue in learning from incidents.
View full coroner's concerns
Errors in Care
1. was started on Syntocinon at 7.15pm on Friday, 22 May 2015. Given the circumstances of her presentation (including meconium stained liquor and infrequent contractions at a late stage of labour), her consultant told me in court that when was seen by a registrar at 2.40pm that afternoon, the registrar should have conducted a full review and started Syntocinon then, some four and a half hours before.
Having spoken to the registrar since, the consultant is unable to explain why that full review and medication commencement did not take place. It is therefore unclear whether this particular registrar, and indeed others on the unit, might be likely to make the same mistake again another time.
2. The notes recorded by that registrar fell significantly short of what can be expected in terms of recording a management plan.
Learning Lessons
3. At ten past midnight on Saturday, 23 May, a different registrar took the decision to allow two hours passive descent before pushing. This was an error of judgement that the registrar had not appreciated even by the time of the inquest, over four months after death, indicating that she had not received appropriate feedback. It is therefore unclear whether this particular registrar, and others on the unit, might be likely to make this same mistake again.
4. The first registrar was not asked to contribute to the hospital’s untoward incident investigation, so there was a systemic failure to understand the value of her input, resulting in a loss of learning for the organisation and for the registrar.
5. Neither the first nor the second registrar was notified of the untoward incident investigation findings, even by the time of inquest, and so the opportunity for them to learn and to improve was lost. This seems to demonstrate a lack of a robust system for learning lessons.
1. was started on Syntocinon at 7.15pm on Friday, 22 May 2015. Given the circumstances of her presentation (including meconium stained liquor and infrequent contractions at a late stage of labour), her consultant told me in court that when was seen by a registrar at 2.40pm that afternoon, the registrar should have conducted a full review and started Syntocinon then, some four and a half hours before.
Having spoken to the registrar since, the consultant is unable to explain why that full review and medication commencement did not take place. It is therefore unclear whether this particular registrar, and indeed others on the unit, might be likely to make the same mistake again another time.
2. The notes recorded by that registrar fell significantly short of what can be expected in terms of recording a management plan.
Learning Lessons
3. At ten past midnight on Saturday, 23 May, a different registrar took the decision to allow two hours passive descent before pushing. This was an error of judgement that the registrar had not appreciated even by the time of the inquest, over four months after death, indicating that she had not received appropriate feedback. It is therefore unclear whether this particular registrar, and others on the unit, might be likely to make this same mistake again.
4. The first registrar was not asked to contribute to the hospital’s untoward incident investigation, so there was a systemic failure to understand the value of her input, resulting in a loss of learning for the organisation and for the registrar.
5. Neither the first nor the second registrar was notified of the untoward incident investigation findings, even by the time of inquest, and so the opportunity for them to learn and to improve was lost. This seems to demonstrate a lack of a robust system for learning lessons.
Responses
Action Taken
The response details multiple actions already completed including educational supervision for the registrar involved, sharing learning points via newsletters and meetings, and implementing a meeting at the start of every maternity serious incident investigation. Planned actions include multidisciplinary meetings, feedback to staff, and communication from the Medical Director regarding record keeping. (AI summary)
The response details multiple actions already completed including educational supervision for the registrar involved, sharing learning points via newsletters and meetings, and implementing a meeting at the start of every maternity serious incident investigation. Planned actions include multidisciplinary meetings, feedback to staff, and communication from the Medical Director regarding record keeping. (AI summary)
View full response
1
Regulation 28: Prevention of Future Deaths Action plan following the report of: Coroner ME Hassell Senior Coroner Inner North London St Pancras Coroner’s Court Camley Street London N1C 4PP
Into the death of: Vasilis Ktorakis Identified MATTERS OF CONCERN for Whittington Health:
No. Matters of concern Key Actions Completion Date Responsible Lead(s) Progress on actions and dates: Evidence of implementation and date of implementation (to be completed once actions are completed) 1 Ms Ktorakis was started on Syntocinon at 7.15pm on Friday, 22 May 2015. Given the circumstances of her presentation
1) Educational supervisor to meet with the registrar (KA) and discuss the learning from this case.
29th January 2016
Vibha Ruparelia, Consultant Obstetrician Vibha Ruparelia met with the registrar shortly after the inquest and went through the learning from this case.
2
(including meconium stained liquor and infrequent contractions at a late stage of labour), her consultant told me in court that when Ms Ktorakis was seen by a registrar at 2.40pm that afternoon, the registrar should have conducted a full review and started Syntocinon then, some four and a half hours before.
Having spoken to the registrar since, the consultant is unable to explain why that full review and medication commencement did not take place. It is therefore unclear whether this particular registrar, and indeed others on the unit, might be likely to make the same mistake again another time.
2) Registrar to complete a reflective statement which will be added to their training and appraisal portfolio.
3) Provide a summary of the case and all the learning points and share with staff via the maternity newsletter, maternity clinical governance committee, the weekly maternity teaching sessions and the trust intranet (the trust intranet includes a section for sharing learning from complaints and incidents).
29th January 2016 (these actions will take place throughout January and will be completed by the end of January)
Clinical Risk Midwife and
Consultant Obstetrician VR to ensure the reflective statement has been completed and added to the portfolio as outlined.
This case was originally shared with the maternity unit in August 2015 via the maternity newsletter
3
2 The notes recorded by that registrar fell significantly short of what can be expected in terms of recording a management plan.
4) As per action points 1 and 2 above.
5) A regular audit of maternity records is undertaken (40 sets of notes a year) and includes a review of 69 standards. Consultants and trainee doctors to be actively involved in the completion of the audit, presentation of the results and action planning. Results of the most recent audit and learning regarding record keeping in this case will be presented at the next clinical audit day (this is a trust wide multidisciplinary learning event).
21st January 2016
, Matron and
Consultant Obstetrician and Oliparambil Ashokkumar, Consultant Obstetrician
3 At ten past midnight on Saturday, 23 May, a different registrar took the decision to allow two hours passive descent before pushing. This was
6) Educational supervisor to meet with the registrar (SA) and discuss the learning from this case.
7) Registrar to complete a reflective statement which 29th January 2016
Consultant Obstetrician and Divisional Director , Chandrima Biswas met with the registrar shortly after the inquest and went through the learning from this case. CB to ensure the reflective statement
4
an error of judgement that the registrar had not appreciated even by the time of the inquest, over four months after death, indicating that she had not received appropriate feedback. It is therefore unclear whether this particular registrar, and others on the unit, might be likely to make this same mistake again.
will be added to their training and appraisal portfolio.
8) As per action 3 above. Consultant Gynaecologist and Director of Research and Innovation has been completed and added to the portfolio as outlined.
4 The first registrar was not asked to contribute to the hospital’s untoward incident investigation, so there was a systemic failure to understand the value of her input, resulting in a loss of learning for the organisation and for
9) A meeting will take place with at the start of every maternity serious incident investigation that includes all the staff involved in the incident and the investigating team. It will be agreed in this meeting who needs to provide a statement and contribute to the process. COMPLETED , Maternity Clinical Governance Manager This was put in place immediately following the outcome of the inquest.
5
the registrar.
5
Neither the first nor the second registrar was notified of the untoward incident investigation findings, even by the time of inquest, and so the opportunity for them to learn and to improve was lost. This seems to demonstrate a lack of a robust system for learning lessons.
10) A multidisciplinary meeting (MDT) will take place at the conclusion of every serious incident investigation that includes all the staff involved in the incident and the investigating team. A wider MDT will take place involving other staff on the unit as relevant.
11) The serious incident action plan template will include a preset recommendation for completion that stipulates feedback must be given to each individual involved who requires feedback. The action will need to include who will provide the feedback and when this will
31st December 2015
Arrangments for this to be in place by 29th January 2016
31st December 2015
, Maternity Clinical Governance Manager
, Consultant Obstetrician and Divisional Director
Head of Integrated Risk Management
6
be done.
12) Medical Director to write to all Divisional Directors regarding the importance of robust record keeping and for this to be cascaded to all staff within their clinical services.
29th January 2016
Medical Director
Regulation 28: Prevention of Future Deaths Action plan following the report of: Coroner ME Hassell Senior Coroner Inner North London St Pancras Coroner’s Court Camley Street London N1C 4PP
Into the death of: Vasilis Ktorakis Identified MATTERS OF CONCERN for Whittington Health:
No. Matters of concern Key Actions Completion Date Responsible Lead(s) Progress on actions and dates: Evidence of implementation and date of implementation (to be completed once actions are completed) 1 Ms Ktorakis was started on Syntocinon at 7.15pm on Friday, 22 May 2015. Given the circumstances of her presentation
1) Educational supervisor to meet with the registrar (KA) and discuss the learning from this case.
29th January 2016
Vibha Ruparelia, Consultant Obstetrician Vibha Ruparelia met with the registrar shortly after the inquest and went through the learning from this case.
2
(including meconium stained liquor and infrequent contractions at a late stage of labour), her consultant told me in court that when Ms Ktorakis was seen by a registrar at 2.40pm that afternoon, the registrar should have conducted a full review and started Syntocinon then, some four and a half hours before.
Having spoken to the registrar since, the consultant is unable to explain why that full review and medication commencement did not take place. It is therefore unclear whether this particular registrar, and indeed others on the unit, might be likely to make the same mistake again another time.
2) Registrar to complete a reflective statement which will be added to their training and appraisal portfolio.
3) Provide a summary of the case and all the learning points and share with staff via the maternity newsletter, maternity clinical governance committee, the weekly maternity teaching sessions and the trust intranet (the trust intranet includes a section for sharing learning from complaints and incidents).
29th January 2016 (these actions will take place throughout January and will be completed by the end of January)
Clinical Risk Midwife and
Consultant Obstetrician VR to ensure the reflective statement has been completed and added to the portfolio as outlined.
This case was originally shared with the maternity unit in August 2015 via the maternity newsletter
3
2 The notes recorded by that registrar fell significantly short of what can be expected in terms of recording a management plan.
4) As per action points 1 and 2 above.
5) A regular audit of maternity records is undertaken (40 sets of notes a year) and includes a review of 69 standards. Consultants and trainee doctors to be actively involved in the completion of the audit, presentation of the results and action planning. Results of the most recent audit and learning regarding record keeping in this case will be presented at the next clinical audit day (this is a trust wide multidisciplinary learning event).
21st January 2016
, Matron and
Consultant Obstetrician and Oliparambil Ashokkumar, Consultant Obstetrician
3 At ten past midnight on Saturday, 23 May, a different registrar took the decision to allow two hours passive descent before pushing. This was
6) Educational supervisor to meet with the registrar (SA) and discuss the learning from this case.
7) Registrar to complete a reflective statement which 29th January 2016
Consultant Obstetrician and Divisional Director , Chandrima Biswas met with the registrar shortly after the inquest and went through the learning from this case. CB to ensure the reflective statement
4
an error of judgement that the registrar had not appreciated even by the time of the inquest, over four months after death, indicating that she had not received appropriate feedback. It is therefore unclear whether this particular registrar, and others on the unit, might be likely to make this same mistake again.
will be added to their training and appraisal portfolio.
8) As per action 3 above. Consultant Gynaecologist and Director of Research and Innovation has been completed and added to the portfolio as outlined.
4 The first registrar was not asked to contribute to the hospital’s untoward incident investigation, so there was a systemic failure to understand the value of her input, resulting in a loss of learning for the organisation and for
9) A meeting will take place with at the start of every maternity serious incident investigation that includes all the staff involved in the incident and the investigating team. It will be agreed in this meeting who needs to provide a statement and contribute to the process. COMPLETED , Maternity Clinical Governance Manager This was put in place immediately following the outcome of the inquest.
5
the registrar.
5
Neither the first nor the second registrar was notified of the untoward incident investigation findings, even by the time of inquest, and so the opportunity for them to learn and to improve was lost. This seems to demonstrate a lack of a robust system for learning lessons.
10) A multidisciplinary meeting (MDT) will take place at the conclusion of every serious incident investigation that includes all the staff involved in the incident and the investigating team. A wider MDT will take place involving other staff on the unit as relevant.
11) The serious incident action plan template will include a preset recommendation for completion that stipulates feedback must be given to each individual involved who requires feedback. The action will need to include who will provide the feedback and when this will
31st December 2015
Arrangments for this to be in place by 29th January 2016
31st December 2015
, Maternity Clinical Governance Manager
, Consultant Obstetrician and Divisional Director
Head of Integrated Risk Management
6
be done.
12) Medical Director to write to all Divisional Directors regarding the importance of robust record keeping and for this to be cascaded to all staff within their clinical services.
29th January 2016
Medical Director
Sent To
- Whittington Hospital NHS Trust
Response Status
Linked responses
1 of 1
56-Day Deadline
14 Dec 2015
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 28 May 2015, I commenced an investigation into the death of Vasilis Ktorakis, who died shortly after birth. The investigation concluded at the end of the inquest on 5 October 2015. (I apologise for the delay in sending this report.) I made an open determination and recorded a medical cause of death of:
1a acute perinatal asphyxia 1b underlying cause unknown.
1a acute perinatal asphyxia 1b underlying cause unknown.
Circumstances of the Death
Following a long labour at the Whittington Hospital, gave birth on Saturday, 23 May 2015. To the great surprise of the healthcare team, Baby Vasilis was born in an extremely poor condition and died very shortly thereafter.
Copies Sent To
, obstetric consultant
obstetric registrar
obstetric registrar
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.