Isabela Suciu

Dear Mr. Harris

Response to Regulation 28 - Prevention of Future Death (PFD) report following inquest into the death of baby Isabela SUCIU. I am writing in response to your report dated 12th August 2023 (assume this should read 12th September 2023 as the date of issue precedes the inquest hearing held on 23 – 24 August
2023). The Trust was alerted of the PFD report on 25 September 2023 via CQC and the court subsequently confirmed notification of the PFD report was erroneously served on another Trust. As such, the Trust is grateful for extension of the response deadline to 20 November
2023. The PFD report highlighted one matter of concern as set out below: o With regards to apparent conflict in applying the Kaiser Permanente Score and NICE guidelines although The Trust have taken a number of steps to address the risk, there appears to remain the opportunity for confusion as the revised Newborn Early Warning Trigger and Track score indicates a different response from Kaiser, when late onset symptoms occur after an asymptomatic period, creating a risk of avoidable delay. We understand the potential for confusion between the revised NEWTT scoring and Kaiser scoring and would like to explain the purpose and scope of both tools and what we have done to mitigate the confusion. Kaiser Permanente is a tool using objective risk factors for sepsis at birth (using maternal information) and the neonatal clinical examination status to give a risk score to guide the management of sepsis. All infants born with risk factors for sepsis (as per NICE CG149 guideline) will have a Kaiser Permanente score to determine the management plan. Prior to the now widely adopted Kaiser Permanente scoring most hospitals used the risks factors in NICE CG149 to determine treatment and antibiotic therapy. However, there were growing concerns of overuse of antibiotics as Early Onset Sepsis only occurs in around 0.7/1000 live births in high income settings, significantly less than the numbers treated for suspected early onset sepsis.

The NEWTT2 scoring chart offers a solution for identifying other babies at risk of deterioration not just babies at risk of sepsis. For example, the NEWTT scoring tool is useful for babies requiring observations for meconium-stained liquor or growth restriction. We are aware that the response on NEWTT2 scoring is different if the baby is treated under the Kaiser Permanente pathway when compared to a baby who is not on the Kaiser pathway and at risk of deterioration for other clinical reasons. With the threshold for intervention being much lower for babies on the Kaiser pathway. Therefore, we do understand that it is important to ensure that it is clear to all staff which pathway the baby is on, as this informs any potential treatment and commencement of antibiotic therapy. Please find set out below details of the actions the Lewisham and Greenwich NHS Trust has already taken to ensure that the difference between the two tools and plans to take in response to the death.
1. Compliance with National Institute for health and Care Excellence (NICE) Guidance for the care of newborn babies The Neonatal service leads have reviewed and updated the following Trust guidelines to be reflective of practice in line with NICE guidance for the care of newborn babies:
• Hypoglycaemia: Management in Neonates Clinical Guideline – updated June 2023
• Kaiser Permanent Score: Early Onset Sepsis Risk Assessment for infants ≥ 34 weeks Guideline - updated December 2022

The Trust has reviewed and is compliant with all recommendations in NICE Guidance (NG) 195: Neonatal Infection; Antibiotics for prevention and treatment.
2. Newborn Early Warning Trigger and Track (NEWTT) Scoring The Trust has updated its paper neonatal notes, which includes the updated NEWTT2 chart, and these were ratified at the Women’s, Sexual Health and Neonates Divisional Governance meeting in October 2023. They were subsequently printed by the Trust Reprographics team and are being implemented with additional teaching and support from practice development midwives throughout both maternity services. All new paper neonatal notes have the Kaiser scoring assessment, pathway and treatment escalation process so that it is clear if a baby is on this pathway. In addition to this we have an assessment tool in the notes which is completed by the midwife or paediatrician following birth to identify which babies are at risk of deterioration, e.g., jaundice, meconium, Kaiser, GBS.
3. Education and Monitoring In addition to the above actions, education sessions were provided for the maternity and transitional care teams to remind staff to always escalate low and high temperatures when performing neonatal observations. The observations for neonates will be prescribed under the Kaiser Permanent pathway, meconium observations pathway or any of the ‘red hat’ pathways and documented in the neonatal notes.
4. Escalation of Hypothermia The Clinical Lead and Senior Matron for Neonatal Services reports that hypothermia is being routinely escalated on the Postnatal Ward. Evidence of this was seen most recently

during the junior doctor’s strikes, when several escalations were made. Most cases of hypothermia reported were attributed to environmental factors which improved when the babies were given skin-to-skin contact or appropriate clothing. However, one escalation resulted in the baby being commenced on intravenous antibiotics and another being admitted to the neonatal unit after their temperature failed to regulate within the expected range which triggered repeated medical reviews. Escalation will continue to be monitored by the Clinical Lead. I would like to assure you that the Trust has taken the concerns raised seriously and learning from this death has been shared at the Divisional ‘Outcomes With Learning’ Group. Should you have any further questions regarding any of the information provided in this letter or require any further information please do not hesitate to contact me.