Theo Young
20 Apr 2020 · Coroner Karen Henderson · Surrey
The coroner's concerns
1. lack of immediate remedial action
“The HSIB specifically requested the Trust not to undertake their own investigation effectively preventing the recognition of causes of concern and therefore being unable to undertake any immediate and necessary remedial action at the earliest opportunity to prevent future deaths”
2. delayed investigation
“HSIB indicated to the Trust at the outset that their investigation would take approximately six months which is highly likely to delay the introduction of any immediate necessary measures by the Trust to prevent further deaths”
3. inaccurate delayed report
“The initial draft report contained factual errors and inaccuracies requiring considerable input by the Trust to resolve. The final report is insufficiently detailed and was completed 18 months after the death, during which time further deaths could have resulted”
Responses
2020-0094-Response-from-Surrey-and-Sussex-Healthcare_Redacted.pdf ↗· Department of Health and Social Care
Stated action
“increased midwifery staffing numbers by 10 full time equivalents and undertake a six monthly Board level review of midwifery staffing”
2020-0094-Response-from-the-Department-of-Health-and-Social-Care.pdf ↗· Department of Health and Social Care
2020-0094-Response-from-the-Healthcare-Safety-Investigation-Branch_Redacted.pdf ↗· Health Services Safety Investigations Body
Stated action
“HSIB places utmost importance on the need to ensure that rapid learning takes place for cases that fall within the eligibility criteria of HSIB's maternity investigation programme. There are several stages throughout HSIB investigations where the opportunity for identifying and addressing safety risks is provided to trusts, and these were implemented during the investigation of baby [the deceased]'s death. 1. It is HSIB policy that all NHS trusts are advised to complete 72-hour reports for cases that are”
Stated action
“services, HSIB investigators also immediately escalate any safety concerns uncovered during the investigation process to the Head of Midwifery and Clinical Director. This case was discussed at our clinical panel at the outset of the investigation, which identified key lines of enquiry, but the panel did not identify any preliminary findings which suggested an immediate risk to patient safety. Through our regular engagement processes, we ensure that prompt actions are taken by trusts in response to any”
Stated action · 10 January 2019
“HSIB held a roundtable review with SaSH Trust on 10 January 2019 which included a discussion of baby [the deceased]'s case. A summary letter was sent to the Head of Midwifery on the same day and outlined HSIB's concerns relating to staffing, escalation, interpretation services and debriefing.”
Stated action · 10 May 2019
“Quarterly thematic reviews are also held with each trust where there are active investigations to share learning accruing from HSIB's maternity investigations across the country, alongside identifying themes for each organisation where there are particular areas of concern. HSIB held quarterly review meetings with SaSH Trust on 10 May 2019, 6 September 2019 and 6 December 2019.”