Luna Lesko
PFD Report
Partially Responded
Ref: 2013-0214
Coroner's Concerns (AI summary)
Delays in essential foetal monitoring and performing a Category 2 Caesarean section, coupled with insufficient out-of-hours theatre capacity, create a real risk of preventable maternal and infant deaths.
View full coroner's concerns
_ The MATTER OF CONCERN can be described as follows_ (1) There was a delay in securing a cardiotocograph (CTG) which she needed after she had meconium liquor at 15.30_ was in the birthing suite and needed to access a labour ward room to have this foetal monitoring: The was due to the labour suite being very busy, but she was transferred and monitoring began at 17.02. accepted expert evidence that what was best in the local context was not to site a CTG machine in the birthing centre, but to ensure access to the labour ward_ Evidence was given that there is now another labour room: Whilst did not conclude that there was now a risk to future babies from this arrangement; it establishes an on going increased capacity of the labour ward, which is relevant to the concern below.
(2) LSCS was required to deliver the baby; due to lack of progression despite augmentation, adverse position and prolonged rupture of membranes with meconium , The decision was taken at 20.00 hours, but delivery was not possible until 21.,40 hours, as theatres were This of hour 40 minutes for a category 2 section was 40 minutes outside the Trust's own guidelines.
(3) The consultant obstetrician reported that this delay, which occurred out of hours, in a unit with over 4000 births per year was unacceptable. It worsens the potential impact; carrying a higher risk of brain damage or death of babies, if there were several emergencies at one time: Staff were reluctant to use the second out of hours (non obstetric) theatre as they cannot then respond to a category emergency. My expert obstetric witness Jof Kings College Hospital, gave an opinion that the out of hours theatre access created a real risk of preventable death, especially wlth the increasing rate of performing LSCSs. He advised me that should be concerned and bring the matter to the attention of the Trust: (4) Whilst the Head of Midwifery reported management changes and compliance with CNST assessment;, she did not provide assurance that the theatre capacity had been increased out of hours. Furthermore it was reported that the Trust is shortly to be disbanded and a new Trust is being formed by merger with another: This may lead to service configuration changes. She reported that the fulure obstetric services were under review. (5) | concluded that a real risk existed that should report to the Trust and the commissioning body; to ensure (hat it was fully appreciated and given appropriate priority in service reconfiguration planning
(2) LSCS was required to deliver the baby; due to lack of progression despite augmentation, adverse position and prolonged rupture of membranes with meconium , The decision was taken at 20.00 hours, but delivery was not possible until 21.,40 hours, as theatres were This of hour 40 minutes for a category 2 section was 40 minutes outside the Trust's own guidelines.
(3) The consultant obstetrician reported that this delay, which occurred out of hours, in a unit with over 4000 births per year was unacceptable. It worsens the potential impact; carrying a higher risk of brain damage or death of babies, if there were several emergencies at one time: Staff were reluctant to use the second out of hours (non obstetric) theatre as they cannot then respond to a category emergency. My expert obstetric witness Jof Kings College Hospital, gave an opinion that the out of hours theatre access created a real risk of preventable death, especially wlth the increasing rate of performing LSCSs. He advised me that should be concerned and bring the matter to the attention of the Trust: (4) Whilst the Head of Midwifery reported management changes and compliance with CNST assessment;, she did not provide assurance that the theatre capacity had been increased out of hours. Furthermore it was reported that the Trust is shortly to be disbanded and a new Trust is being formed by merger with another: This may lead to service configuration changes. She reported that the fulure obstetric services were under review. (5) | concluded that a real risk existed that should report to the Trust and the commissioning body; to ensure (hat it was fully appreciated and given appropriate priority in service reconfiguration planning
Responses
Action Planned
The hospital plans to relocate elective lists to the main theatre unit by the end of January 2014, which would free up the obstetric unit theatre for emergencies and allow midwives and doctors to focus on labouring women. (AI summary)
The hospital plans to relocate elective lists to the main theatre unit by the end of January 2014, which would free up the obstetric unit theatre for emergencies and allow midwives and doctors to focus on labouring women. (AI summary)
View full response
Dear Dr Harris REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Baby Luna Lesko, dod; 22nd February 2011, Case number: 00787/11 am writing in response to your report dated 23 August 2013, and referenced above. As the report was sent to both Lewisham Healthcare Trust (LHT) and NHS Lewisham's Clinical Commissioning Group (CCG) my reply is on behalf of both organisations. LHT acknowledge the concern raised about limited access to theatres for mothers requiring lower segment Caesarean section out of hours_ The maternity unit at University Hospital Lewisham (UHL) provides a 24 hour service for safe delivery of women in labour: There is also time provision for planned (elective) delivery and other obstetric procedures_ Our unit is a busy maternity unit with delivery of 4129 births in 2012 including 895 in the midwifery led Birth Centre. In 2011 the UHL maternity unit had a total of 3955 births. Lewisham is one of the few remaining maternity units that has a equipped and staffed obstetric theatre located on labour ward , that operates only during normal working hours (08.00
17.00 Monday to Friday): This is replaced by a fully staffed theatre in the main theatre unit located very near to the labour ward, outside these hours. This dedicated emergency theatre is kept free at all times for emergency deliveries, and if an emergency takes place, a second out of hours general theatre is kept free from general activity until the obstetric theatre is vacated_ The issues raised in your report focused on the unit's ability to cope with multiple emergency Caesarean sections at the same time_ The Royal College of Obstetricians and Gynaecologists advise that maternity units with a birth rate above 4000 births require two operating theatres. The main points about emergency provisions centre on the availability of theatre space, obstetric team, anaesthetic team and theatre staff (nurses and operating department practitioners): will address these in turn: day fully
The College recommends that an operating theatre dedicated for obstetrics should be close to the labour ward, or preferably within it. Lewisham's obstetricians have requested that the obstetric theatre located on labour ward be changed from being primarily used for elective Caesarean sections to being the emergency obstetric theatre 24 hours a day: We have reviewed whether there are any reasons why this cannot be the case and propose to implement the change by the end of March 2014 As mentioned above, the obstetric team already has access to a second theatre out of hours and at weekends In addition, we are assessing whether access to a second theatre can also be provided during normal working hours whilst at the same time minimising the impact on the Trust's other surgical activity and clinical priorities This includes reviewing current theatre utilisation by the whole of the Women's Division: With the introduction of middle grade obstetricians to the obstetric rota from 2012, there has been and continues to be adequate cover by the obstetricians to perform multiple emergency caesarean sections 24 hours a day if required: The same applies to the anaesthetic team with the introduction of middle grade anaesthetic cover. This allows a Specialist Registrar for anaesthetics to be available for an obstetric emergency and a middle grade anaesthetist to be available in case of multiple emergency caesarean sections: In addition to these, there are two consultant anaesthetists on call with one available to cover if required An additional theatre team would be required to ensure that two emergency theatres were guaranteed for the maternity unit: This would include an Operating Department Practitioner and nursing staff. The Women's and Surgery Clinical Divisions are developing a business case for this additional resource, which will be reviewed at Executive Director level within the Trust and discussed with Lewisham CCG. The timescale for this is 3 to 6 months The maternity unit currently has an elective Caesarean section list once a week during normal working hours, which is scheduled in main theatres. Our plan is to increase this to three times a week within the main theatre unit by the end of January 2014,as this would release the obstetric unit theatre for emergencies: Theatre allocation has already been identified and planning of additional staffing resource is underway: The additional elective Iists in main theatres would also enable midwives and on call doctors to be freed up to focus on labouring women. At present, elective procedures sometimes have to be cancelled to make way for emergency cases; the former may then become urgent or emergency situations requiring out of hours theatre time As you may be aware Lewisham Healthcare NHS Trust formally merged with Queen Elizabeth Hospital on 1st October 2013 forming Lewisham and Greenwich NHS Trust. Although service configurations been proposed by the Trust Special Administrator for the former South London Healthcare NHS Trust; those proposed changes are still under the judicial review process: potential time line resulting from the conclusion of that review will not have a bearing on the actions to be undertaken by the Trust in relation to your report: In any new service configuration we endeavour to ensure that the theatre capacity of our maternity units are designated and configured bearing in mind the advice of the Royal College of Obstetricians and Gynaecologists: fully have Any will
Going forward, the delivery of the above actions wll be monitored via the Clinical Quality and Risk Group chaired by]_ Nurse Director at Lewisham CCG. wish to assure you that my team and take this risk seriously and will ensure that the actions outlined above are taken in the hope that this may reduce the risk of future deaths, although this risk was not a contributory factor to the outcome in the case that prompted your notice to me. Should you have any questions in regard to any of the actions taken or require any further information please do not hesitate to contact me
17.00 Monday to Friday): This is replaced by a fully staffed theatre in the main theatre unit located very near to the labour ward, outside these hours. This dedicated emergency theatre is kept free at all times for emergency deliveries, and if an emergency takes place, a second out of hours general theatre is kept free from general activity until the obstetric theatre is vacated_ The issues raised in your report focused on the unit's ability to cope with multiple emergency Caesarean sections at the same time_ The Royal College of Obstetricians and Gynaecologists advise that maternity units with a birth rate above 4000 births require two operating theatres. The main points about emergency provisions centre on the availability of theatre space, obstetric team, anaesthetic team and theatre staff (nurses and operating department practitioners): will address these in turn: day fully
The College recommends that an operating theatre dedicated for obstetrics should be close to the labour ward, or preferably within it. Lewisham's obstetricians have requested that the obstetric theatre located on labour ward be changed from being primarily used for elective Caesarean sections to being the emergency obstetric theatre 24 hours a day: We have reviewed whether there are any reasons why this cannot be the case and propose to implement the change by the end of March 2014 As mentioned above, the obstetric team already has access to a second theatre out of hours and at weekends In addition, we are assessing whether access to a second theatre can also be provided during normal working hours whilst at the same time minimising the impact on the Trust's other surgical activity and clinical priorities This includes reviewing current theatre utilisation by the whole of the Women's Division: With the introduction of middle grade obstetricians to the obstetric rota from 2012, there has been and continues to be adequate cover by the obstetricians to perform multiple emergency caesarean sections 24 hours a day if required: The same applies to the anaesthetic team with the introduction of middle grade anaesthetic cover. This allows a Specialist Registrar for anaesthetics to be available for an obstetric emergency and a middle grade anaesthetist to be available in case of multiple emergency caesarean sections: In addition to these, there are two consultant anaesthetists on call with one available to cover if required An additional theatre team would be required to ensure that two emergency theatres were guaranteed for the maternity unit: This would include an Operating Department Practitioner and nursing staff. The Women's and Surgery Clinical Divisions are developing a business case for this additional resource, which will be reviewed at Executive Director level within the Trust and discussed with Lewisham CCG. The timescale for this is 3 to 6 months The maternity unit currently has an elective Caesarean section list once a week during normal working hours, which is scheduled in main theatres. Our plan is to increase this to three times a week within the main theatre unit by the end of January 2014,as this would release the obstetric unit theatre for emergencies: Theatre allocation has already been identified and planning of additional staffing resource is underway: The additional elective Iists in main theatres would also enable midwives and on call doctors to be freed up to focus on labouring women. At present, elective procedures sometimes have to be cancelled to make way for emergency cases; the former may then become urgent or emergency situations requiring out of hours theatre time As you may be aware Lewisham Healthcare NHS Trust formally merged with Queen Elizabeth Hospital on 1st October 2013 forming Lewisham and Greenwich NHS Trust. Although service configurations been proposed by the Trust Special Administrator for the former South London Healthcare NHS Trust; those proposed changes are still under the judicial review process: potential time line resulting from the conclusion of that review will not have a bearing on the actions to be undertaken by the Trust in relation to your report: In any new service configuration we endeavour to ensure that the theatre capacity of our maternity units are designated and configured bearing in mind the advice of the Royal College of Obstetricians and Gynaecologists: fully have Any will
Going forward, the delivery of the above actions wll be monitored via the Clinical Quality and Risk Group chaired by]_ Nurse Director at Lewisham CCG. wish to assure you that my team and take this risk seriously and will ensure that the actions outlined above are taken in the hope that this may reduce the risk of future deaths, although this risk was not a contributory factor to the outcome in the case that prompted your notice to me. Should you have any questions in regard to any of the actions taken or require any further information please do not hesitate to contact me
Sent To
- University Hospital Lewisham
Response Status
Linked responses
1 of 2
56-Day Deadline
18 Oct 2013
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 14th April 2011,_ an inquest was opened into the death of Luna Lesko, aged 26 The inquest concluded at Soulhwark Coroner's Court on 16/h August 2013. The conclusion of the inquest was a narrative (see section 4 below):
Circumstances of the Death
Baby Luna Lesko died at Universily Lewisham Hospital at 16.40 on 2Oth March 2011, after discontinuing intensive care, due to unsurvivable brain damage. Her mother was 41+4 weeks pregnant on 22nd February; became fully dilated at 14.30, with meconium liquor at 15.30. Syntocinon was begun at 19.00, increased at 19.48 and stopped at 20.20 as failure to progress with OP position. CTG remained normal, The baby was delivered by LSCS at 21.45 with Apgar 9 and normal blood gases. She was put to the breast at 22.30 until 22.49. The paediatric doctor attending birth asked for meconium observations to be done as per Trust Protocol. Although there were records f two readings of pulse; resps and temperature, it was concluded that the full range of observations were not done by the attending midwife, in particular at around 23.15, when the baby was lying wrapped on the mother's chest; It was found that neither the prenatal events nor breast feeding contributed to death. Contributory causes were the position of the baby since there was at some time an occlusion of the airway and the fallure to perform the required observations in particular observation of skin colour; This failure amounted to neglect: She was found collapsed with no respirations, and floppy at about 23.28, was resuscitated, required intubation and ventilation after minutes and was transferred to
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe your organization(s) have the power to take such action_
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.