Harry Richford
3 Feb 2020 · Coroner Christopher Sutton-Mattocks · North East Kent
This report repeats 2 earlier warnings, and was raised again 3 times later. See the linked reports.
The coroner's concerns
1. locum registrar without assessment or supervision
“recruited as a locum registrar by the Hospital Trust without there appearing to have been any assessment of his skills and abilities or any supervision of him at the hospital”
2. lack of competence assurance for locums
“current policy of the East Kent Trust states that it is the responsibility of the healthcare professional who will be supervising the locum to assure themselves of his/her competence”
3. lack of feedback on locum competence
“had worked two night time shifts at the QEQM before the night of [the deceased]'s birth”
4. lack of clarity in obstetric emergency processes
“risk to the life of both mothers and babies if there is a lack of clarity as to the processes or the need to take prompt action where it is necessitated in the event of an obstetric concern or emergency developing”
5. staff confusion about consultant escalation timing
“There appeared to be from the evidence given at the inquest substantial confusion amongst staff as to when a consultant should be called at night.”
6. delayed response to night time emergencies
“current contracts at the East Kent Trust permit consultants to live up to 30 minutes travel time from the hospital”
Linked reports
Closely relatedConfidence 0.85 · high
Earlier report
“It was apparent that the Midwives involved with [the deceased]'s birth and a Junior Obstetrician, appeared not to understand that the cardiotocograph (CTG) trace was abnormal on several occasions.”
This report
“There is a risk to the life of both mothers and babies if there is a lack of clarity as to the processes or the need to take prompt action where it is necessitated in the event of an obstetric concern or emergency developing.”
Closely relatedConfidence 0.80 · moderate
Earlier report
“the ED on call consultant arrangements meant that long wait times would not in themselves trigger on call consultants being asked to attend the hospital.”
This report
“There appeared to be from the evidence given at the inquest substantial confusion amongst staff as to when a consultant should be called at night.”
Identical hazardConfidence 0.90 · high
This report
“The current contracts at the East Kent Trust permit consultants to live up to 30 minutes travel time from the hospital.”
Later report
“the Trust practice, as opposed to Policy, is that the on-call Consultant cannot be more than 30 minutes from either Brighton or Haywards Heath.”
Closely relatedConfidence 0.80 · moderate
This report
“There is a risk to the life of both mothers and babies if there is a lack of clarity as to the processes or the need to take prompt action where it is necessitated in the event of an obstetric concern or emergency developing.”
Later report
“During the course of the evidence I was informed that the clinicians consider that there is insufficient guidance as to the management actions that should be taken in the event of an abnormal antenatal CTG.”
Closely relatedConfidence 0.70 · moderate
This report
“was recruited as a locum registrar by the Hospital Trust without there appearing to have been any assessment of his skills and abilities or any supervision of him at the hospital.”
Later report
“I am concerned that no medical record appears to exist of the examination of [the deceased] which was undertaken by the Locum Registrar in Paediatrics which resulted was discharged from hospital.”
Responses
2020-0117-Response-from-Department-of-Health-and-Social-Care.pdf ↗· Department of Health and Social Care
Stated action
“the CQC continues to be in close contact with the Trust and will take regulatory action if it decides that it is necessary”
Stated action
“England and NHS Improvement (NHSEI) have put in place an intensive programme of support at the Trust”
Stated action
“The Trust must continue to strengthen its processes to learn from deaths and develop an open, learning culture for the safety of its patients”
Stated action
“the Trust has developed its approach to engaging with families when unexpected deaths occur and to involve families in the investigation of these 2”
Stated action
“the Trust Board is taking these matters very seriously and has welcomed the national support being provided.”