From the Rl Hon Jeremy Hunt MP Secretary of State for Health Department of Health Richmond House 79 Whitehall London POC1 824991 SWIA 2NS Tel: 020 7210 3000 Ms L Hashmi Mb-sofs@dh-gsi govuk Assistant Coroner HM Coroner' s Court The Phoenix Centre Church Street Heywood 4 JAN 2014 OLIO ILR Dc MILL~: , Thank you for your letter following the inquest into the death of Jack William Partington. In your report you state that Jack died from hypoxia; insufficient ventilation of thc consequent upon the prescription of Atracuriam and insufficient artificial ventilation; and respiratory distress syndrome. You raise the following concerns about the nursing and medical care of Jack: a lack of :l neonatal nurse handover at shift individualised neonatal care nursing plan and routine checks of medical records for new neonatal admissions nursing staff took treatment decisions in isolation and without consulting all available information disposable exhaled carbon dioxide detectors were not routinely used on the Neonatal Unit (NNU) and are not currently routinely used in many NNUs throughout the country no national standardised policies O1 guidance on the management and administration of paralysing agents to neonates in need of intubation O1 management of ventilation in neonates No single individual was allocated to oversee and monitor the ventilator pressure dial following intubation lungs change,

Inote that you have sent a Regulation 28 report to the local NHS Trust for its response I believe that the issues concerning staffing, staff training; governance and clinical issues are local issues that should properly be addressed by the Trust: NHS England is responsible for commissioning neonatal critical care services and has issued a standard contract for these services, which was adopted from 1 October
2013. In line with the contract; services should ensure robust clinical governance arrangements are in place. Services should also ensure there are robust monitoring and reporting arrangements in accordance with performance requirements and demonstrate evidence of continuing improvement of quality and responsiveness year on year through evaluation and audit. Guidance on the use of carbon dioxide detectors and the management and administration of paralysing agents to neonates in need of intubation should already be covered in the care guidance of every neonatal service. We do not therefore believe issuing duplicate guidance would be valuable. The Resuscitation Council (UK) has issued updated guidance on new-born life support, which recommends detection of exhaled carbon dioxide in addition to clinical assessment as the most reliable method to confirm placement of a tracheal tube in neonates with a spontaneous circulation: We have been advised by NHS England that carbon dioxide monitors are being used increasingly in neonatal units However;, their use in individual cases is a matter for the clinical judgement of the health professionals involved. The use of muscle relaxants is common practice in Neonatal Intensive Care Units as it is recognised good practice to give muscle relaxants for intubation together with pain relief: I will ensure that this case is notified to the British Association of Perinatal Medicine. In this way, the issues of concern will be brought to the attention of other neonatal teams throughout the country via the Association's quality care process_ I hope that this response is helpful and 1 am grateful to you for bringing the circumstances of Jack's death to my attention U jaws JEREMY HUNT