Thomas Beaty
PFD Report
Partially Responded
Ref: 2015-0130
Coroner's Concerns (AI summary)
Guidance on instrumental delivery was ambiguous and potentially open to misinterpretation, lacked operational definitions for terms like 'imminent', and the term 'gentle' traction was misleading; furthermore, it's difficult for Trusts to change guidance until the RCOG issues changes/improvements.
View full coroner's concerns
1. Instrumental Delivery Guidance
— the Court heard how local/national protocols and training programmes are routinely based on guidance issued by the Royal College of Obstetricians and NICE. The guidance in use at the time of Thoma& birth was found to be ambiguous, misleading and potentially open to misinterpretation. A key example was: ‘When to abandon the procedure:
• No evidence of progressive descent with each pull
• No evidence of imminent birth following 3 pulls of a correctly placed instrument by an experienced operator...’ The first point by implication must mean that where there is no descent with the first pull, then the procedure ought to be abandoned, yet the second point suggests abandonment after a 3 rd traction.
2. Terminology
- The RCOG Guidance did not provide operational definitions for words such as ‘imminent’ (vis a vis birth) or ‘crowning’. This was particularly important in Thomas’ case, as it had a bearing on the decision making processes applied during the course of the forceps delivery.
3. Traction
- The term ‘gentle’ (traction) forming the ‘G’ of the algorithm within the Trust’s protocol was misleading and not in line with the RCOG Guidance. The clinical evidence suggested that in most (if not all) cases mild to moderate traction is routinely applied by clinicians in order to ensure safe and successful instrumental delivery. Whilst it was accepted that this was often subjective, the term ‘gentle’ was clinically out with.
4. Development of Trust Guidance
— it is difficult for Trusts to change their guidance until and unless there is a change/material improvement in the Guidance issued by the RCOG.
— the Court heard how local/national protocols and training programmes are routinely based on guidance issued by the Royal College of Obstetricians and NICE. The guidance in use at the time of Thoma& birth was found to be ambiguous, misleading and potentially open to misinterpretation. A key example was: ‘When to abandon the procedure:
• No evidence of progressive descent with each pull
• No evidence of imminent birth following 3 pulls of a correctly placed instrument by an experienced operator...’ The first point by implication must mean that where there is no descent with the first pull, then the procedure ought to be abandoned, yet the second point suggests abandonment after a 3 rd traction.
2. Terminology
- The RCOG Guidance did not provide operational definitions for words such as ‘imminent’ (vis a vis birth) or ‘crowning’. This was particularly important in Thomas’ case, as it had a bearing on the decision making processes applied during the course of the forceps delivery.
3. Traction
- The term ‘gentle’ (traction) forming the ‘G’ of the algorithm within the Trust’s protocol was misleading and not in line with the RCOG Guidance. The clinical evidence suggested that in most (if not all) cases mild to moderate traction is routinely applied by clinicians in order to ensure safe and successful instrumental delivery. Whilst it was accepted that this was often subjective, the term ‘gentle’ was clinically out with.
4. Development of Trust Guidance
— it is difficult for Trusts to change their guidance until and unless there is a change/material improvement in the Guidance issued by the RCOG.
Responses
Noted
The Department of Health acknowledges the concerns raised about RCOG guidance and has forwarded the coroner's report to the RCOG. (AI summary)
The Department of Health acknowledges the concerns raised about RCOG guidance and has forwarded the coroner's report to the RCOG. (AI summary)
View full response
A Fron Ben Gummer MP Parliamentary Under Secretary of State for Care Quality Department of Hea th Richmond House 79Wh’t h II London POC5 931741 SW1A2NS f Tel: Lisa Hashmi Area Coroner Greater Manchester North 22 JUL 2015 HM Coroner’s Court
- The Phoenix Centre Heywood OL1O 1LR Ltc ph Thank you for your letter of to the Secretary of State for Health about the death of baby Thomas. I am responding as the Minister with responsibility for maternity policy at the Department of Health. I was so very sorry to hear of baby Thomas’ death. The death of a child is always a terrible tragedy and my heart goes out to Thomas’ parents. I would be grateful if you would pass my condolences to them. Your report detailed the terrible sequence of events which led to baby Thomas’ birth and injury on 12 th April 2015. You had a number of concerns about the guidance issued by the Royal College of Obstetricians and Gynaecologists (RCOG), which the inquest found to be ambiguous, misleading and potentially open to misinterpretation, giving the example that the RCOG guidance did not provide operational definitions for words such as ‘imminent’ (vis a vis birth) or ‘crowning’. You also noted that it is difficult for Trusts to change their guidance until and unless there is a change/material improvement in the guidance issued by the RCOG. While local maternity and neonatal care providers must determine how best to deliver services in their area, in doing so we would expect them to give due regard to RCOG and other professional guidance. To this end, a copy of your report has been sent to the RCOG to make them aware of the concerns you have raised and I understand that they have responded to you directly.
I thank you foing this matter to our attention. BEN GUMMER a I;
- The Phoenix Centre Heywood OL1O 1LR Ltc ph Thank you for your letter of to the Secretary of State for Health about the death of baby Thomas. I am responding as the Minister with responsibility for maternity policy at the Department of Health. I was so very sorry to hear of baby Thomas’ death. The death of a child is always a terrible tragedy and my heart goes out to Thomas’ parents. I would be grateful if you would pass my condolences to them. Your report detailed the terrible sequence of events which led to baby Thomas’ birth and injury on 12 th April 2015. You had a number of concerns about the guidance issued by the Royal College of Obstetricians and Gynaecologists (RCOG), which the inquest found to be ambiguous, misleading and potentially open to misinterpretation, giving the example that the RCOG guidance did not provide operational definitions for words such as ‘imminent’ (vis a vis birth) or ‘crowning’. You also noted that it is difficult for Trusts to change their guidance until and unless there is a change/material improvement in the guidance issued by the RCOG. While local maternity and neonatal care providers must determine how best to deliver services in their area, in doing so we would expect them to give due regard to RCOG and other professional guidance. To this end, a copy of your report has been sent to the RCOG to make them aware of the concerns you have raised and I understand that they have responded to you directly.
I thank you foing this matter to our attention. BEN GUMMER a I;
Action Taken
The Pennine Acute Hospitals Trust reviewed and revised the Guideline for Assisted Vaginal Delivery to provide staff with greater clarity and guidance regarding consultant presence for trial in theatre. The guideline was amended to state to abandon the procedure when there is no descent even after the 1st pull. (AI summary)
The Pennine Acute Hospitals Trust reviewed and revised the Guideline for Assisted Vaginal Delivery to provide staff with greater clarity and guidance regarding consultant presence for trial in theatre. The guideline was amended to state to abandon the procedure when there is no descent even after the 1st pull. (AI summary)
View full response
Dear Ms Hashmi Re: Inquest for Baby Thomas Beaty 24th 27t March 2015 am responding to the concerns you raised in the Regulation 28 Report (o Prevent Future Deaths issued on 31s March 2015, in relation Baby Thomas Beaty. In light of the findings from the inquest the investigation the Trust taken the following actions described below: Instrumental Delivery Guidance Since the sad death of Thomas Beaty, the reviewed revised the Guideline for Assisted Vaginal Delivery order provide staff with greater clarity and guidance regarding the requirement for Consultant presence for trial in theatre if the operator is less than ST6. Additional guidance was also added with regards to the flexion point, complications of instrumental deliveries_ and disimpaction of the head. This guideline was ratified in December 2014, Inemediately following the inquest & directive Was issued to Ihe obstetric medical team highlighting the; requirement for a Consuitant Obstetrician to be present in theatre for all trials of instrumental deliveries regardless of the level of experience of the Middle Grade operator The guideline was amended to reflect this requirement and an audit undertaken on both inpatient sites in April to provide assurance that this requirement was being met consistently. Upon receipt of the concerns you raised in the Regulation 28 Report to Prevent Future Deaths the guideline has been reviewed and revised further order address the areas that were considered ambiguous, misleading and potentially open to misinterpretation Instrumental Delivery Guidance Guideline amended to state to abandon the procedure When there is no descent even after the Ist pull: Terminology An explanation of the terms imminent and crowning has been added to the guideline: It is now stated in Section 6.2.6: delivery is imminent as evidenced by crowning (when the widest part of the babys head (bi-parietal diameter) is at the perineum and does not slip back in between contractions) and has Trust and
Traction The guidance around traction was taken from the ASLO (Advanced Lile Suppor Obstetrics) course manual ard has been amended and the lerm gentle' removed_ The 'G of the algorithm now reads' Moderate traction pulling downwards, sweeping in a large arc lowards (he operator, almost completing a 180 degree curve (Pajot's manoeuvre): Development of Trust Guidance We have made interim changes to the Trust guideline whilst waiting for the RCOG to respond the recommendations. However we will review again once the RCOG recommendations have been received The amended guideline has been circulated to the obstetric medical team for their comments . The final document will be ratified in June 2015 and will be sent t0 you following this_ am also including the Guideline for Assisled Vaginal Delivery for your information would wish to offer sincere condolences behalf of myself the maternity team to Thomas' parents and family. Kind regards
Traction The guidance around traction was taken from the ASLO (Advanced Lile Suppor Obstetrics) course manual ard has been amended and the lerm gentle' removed_ The 'G of the algorithm now reads' Moderate traction pulling downwards, sweeping in a large arc lowards (he operator, almost completing a 180 degree curve (Pajot's manoeuvre): Development of Trust Guidance We have made interim changes to the Trust guideline whilst waiting for the RCOG to respond the recommendations. However we will review again once the RCOG recommendations have been received The amended guideline has been circulated to the obstetric medical team for their comments . The final document will be ratified in June 2015 and will be sent t0 you following this_ am also including the Guideline for Assisled Vaginal Delivery for your information would wish to offer sincere condolences behalf of myself the maternity team to Thomas' parents and family. Kind regards
Sent To
- Department of Health and Social Care
- Pennine Acute Hospitals NHS Trust
- Royal College of Obstetricians and Gynaecologists
Response Status
Linked responses
2 of 3
56-Day Deadline
26 May 2015
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 24 th March 2015, I commenced an investigation into the death of infant Thomas Beaty
Circumstances of the Death
On the 11 th April 2014, the deceased’s mother went into spontaneous labour (39 weeks gestation). There was delayed stage II and as a result, the medical team caring for mother and baby proceeded to manually rotate the foetus (he was in malpresentation), to carry out a trial of instrumental delivery (forceps) in theatre with an action plan set in the event that this intervention failed. The instrumental delivery was abandoned, baby’s head manually disimpacted and an emergency caesarean section carried out. At birth (00:31), the deceased’s APGARS were good and he appeared healthy. A cord blood gas was taken, the result of which was marginally abnormal. At 02:20, the deceased started to bleed and rapidly collapsed. He had suffered a catastrophic head injury (a rare but recognised complication of necessary medical intervention) resulting in hypovolaemic shock and hypoxic brain ischaemia. He developed bleeding complications (disseminating intravascular coagulation), deteriorated rapidly and died 26 hours after birth.
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