Scarlett Sinclair
PFD Report
Historic (No Identified Response)
Ref: 2014-0059
Coroner's Concerns (AI summary)
The policy for assessing a baby's wellness and stability prior to transfer between neonatal units needs urgent review, as babies are being transferred in an unstable condition.
View full coroner's concerns
The MATTERS OF CONCERN as follows_ During the inquest evidence was given from the Consultant Locum Neonatologist at Oxford as to how a baby is assessed as suitable for transfer to another neonatal unit;, also heard evidence from a Consultant Neonatologist from Bristol who confirmed that the assessment of suitability for transfer from the United Hospitals Bristol NHS Foundation Trust means that a baby is not transferred to another neonatal unit until they are in a much more stable condition being due are being
Iwould therefore ask that you review your policy for assessing a babies wellness, stability and indeed suitability_prior to approving that baby fit for transfer between neonatal units
Iwould therefore ask that you review your policy for assessing a babies wellness, stability and indeed suitability_prior to approving that baby fit for transfer between neonatal units
Sent To
- Oxford University Hospitals NHS Trust
Response Status
Linked responses
0 of 1
56-Day Deadline
31 Mar 2014
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 15th February 2013 commenced an investigation into the death of Scarlett Lucie SINCLAIR, Aged 25 days. The investigation concluded at the end of the inquest on 31st January 2014. The conclusion of the inquest was la Fulminant necrotising enterocolitis Hypoxic ischaemic encephalopathy and chronic lung disease and history of Twin to Twin transfusion CONCLUSION: Natural Causes
Circumstances of the Death
Scarlett was born at 28 weeks gestation she one of twin girls who were both initially managed in Oxford_ The plan was to transfer Scarlett to Bristol as this was nearer to her home and am told that this is standard practice. She was therefore transferred to the neonatal unit at Southmead Hospital at the age of 23 days on 6"h February: Within hours of transferred she became unwell: was told that around 3-4 a.m. she became more pale and her abdomen was distended. Medical management was commenced with a view to treating necrotising enterocolitis, again was told during the inquest that this was standard management and an X-ray was taken. At Zam there was an acute deterioration which necessitated surgical involvement and Scarlett was transferred for surgical management to another hospital close by: Sadly the surgeon confirmed that there was nothing that could be done to the extent of the necrosis and Scarlett died a few hours later:
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action:
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.