Source · Prevention of Future Deaths

Alissa Norton

Ref: 2024-0108 Date: 26 Feb 2024 Coroner: Joanne Andrews Area: West Sussex, Brighton and Hove 1 response identified · 1 indexed addressee View PDF

AI-generated concerns summaryThe coroner noted limited and retrospectively completed medical notes for Alissa following her birth, with some entries based on assumption rather than first-hand knowledge, hindering subsequent clinicians.

Date 26 Feb 2024

56-day deadline 22 Apr 2024 est. estimated from the report date

Responses identified 1 of 1

Child Death (from 2015)

Coroner's concerns

AI summary

The coroner noted limited and retrospectively completed medical notes for Alissa following her birth, with some entries based on assumption rather than first-hand knowledge, hindering subsequent clinicians.

View full coroner's concerns

1. Alissa Claire Norton was born on 18 April 2022 at 39 + 5 weeks gestation at Worthing Hospital. At the time of and after Alissa’s birth there were two midwives present as per Trust Policy. One midwife was primarily looking after Mrs Norton and the other her daughter Alissa.
2. The evidence that I heard was that the majority of the notes which were adduced in evidence as to the events and treatment of Alissa were completed retrospectively on the next day (19 April 2022) by the midwife who cared for Mrs Norton. There were very limited notes completed by the midwife caring for Alissa at the time or at any time thereafter.
3. Therefore, there was limited documented information available to treating clinicians following Alissa’s birth as to the events and treatment which had been provided to her.
4. The inquest heard that some of the notes completed retrospectively were based on assumption rather than first hand knowledge. This was not clear in the notes.

Responses

1 respondent

University Hospitals Sussex NHS Foundation Trust

NHS Trust

Letter dated 17 Apr 2024 PDF

AI-classified response stance Action Taken

AI-generated response summary

• The Trust disseminated messages to maternity and all Trust staff, and at various meetings, regarding the importance of accurate and contemporaneous record keeping. • A process was implemented for labour ward coordinators to check that all staff had completed their documentation before leaving the shift. • An audit of maternity records was completed to assess the quality and prevalence of retrospective entries and record keeping, with an ongoing audit planned.

View full response

Dear Ms Andrews

Response to the Regulation 28: Report to Prevent Future Deaths following the Inquest touching upon the death of Alissa Norton.

This letter is to outline the actions taken by University Hospitals Sussex NHS Foundation Trust following the receipt of the Regulation 28 report dated 26 February 2024.

The maternity service and wider organisation have taken the concerns raised by the Coroner extremely seriously.

The following actions have been completed or are in progress:

1. Sharing of a ‘message of the week’ within maternity on 4th March 2024 and a global message to all Trust staff on 5th April 2024 regarding the importance of accurate and contemporaneous record keeping, adhering to the Nursing and Midwifery Council (NMC) and General Medical Council (GMC) codes of conduct.
2. Sharing of the message outlined in point 1 at the monthly Trust wide Nursing, Midwifery and Allied Health Professional Quality and Safety meeting on 2nd April 2024, Quality Governance Steering Group on 18th March 2024, Patient and Quality Committee on 26th March 2024, and Trust Board on 28th March 2024.
3. Sharing of the outlined in point 1 at the joint obstetric consultant meeting on 1st March 2024.
4. Action as part of the shift ‘check out’ that the labour ward coordinator checks that all staff have completed their documentation before leaving the shift.

5. An audit of maternity records to assess the quality and prevalence of retrospective entries and record keeping as a whole has been completed. The retrospective notes audit will be an ongoing audit as an addition to the service annual audit plan. The results will be shared within the Quality and safety meetings and newsletters during April and May 2024.
6. Appropriate individual action has been taken with the midwives involved in this case and is ongoing.

Report sections

Investigation and inquest

On 13 July 2022 I commenced an investigation into the death of Alissa Claire NORTON aged 4 Days. The investigation concluded at the end of the inquest on 22 February 2024. The conclusion of the inquest was that: Alissa Claire Norton died on 22 April 2022 at the Royal Sussex County Hospital, Eastern Road, Brighton from a hypoxic ischaemic encephalopathy caused by chorioamnionitis which she was exposed to prior to her birth on 18 April 2022.

Circumstances of the death

Alissa Claire Norton died on 22 April 2022 at the Royal Sussex County Hospital, Eastern Road, Brighton from a hypoxic ischaemic encephalopathy caused by chorioamnionitis which she was exposed to prior to her birth on 18 April 2022 at Worthing Hospital, West Sussex.

Copies sent to

Maternity and Newborn Safety Investigations Special Health Authority (MSNI)

Similar PFD reports

Shared signals

Report details

Reference: 2024-0108
Date of report: 26 February 2024
Coroner: Joanne Andrews
Coroner area: West Sussex, Brighton and Hove

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 22 Apr 2024 (estimated from the report date).

Sent to

University Hospitals Sussex NHS Foundation

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

Contains public sector information licensed under the Open Government Licence v3.0.