Teegan Barnard

Dear Coroner,

Re: Regulation 28 Report to Prevent Future Deaths – Teegan Marie Barnard who died on 7th October 2019.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 17th January 2023 concerning the death of Teegan Marie Barnard on 7 October 2019. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Teegan’s family and loved ones. NHS England are keen to assure the family and the coroner that the concerns raised about Teegan’s care have been listened to and reflected upon.

I am also grateful for the further time granted to respond to your Report, and I apologise for any anguish this delay may have caused Teegan’s family or friends. I realise that responses to Coroner Reports can form part of the important process of family and friends coming to terms with what has happened to their loved ones and appreciate this will have been an incredibly difficult time for them.

NHS England have reviewed the response to your Report from University Hospitals Sussex NHS Foundation Trust (hereafter "the Trust") whom we consider are the most appropriate body to respond to the concerns raised. We note that the Trust has identified learning points and strengthened its training for relevant staff members following Teegan’s death as well as the ongoing improvement work to their maternity services, implemented through the Maternity Improvement Programme.

Resuscitation algorithm (4 H’s & 4 T’s)* for PEA cardiac arrest and surgical emphysema

You raised the concern that the resuscitation algorithm of 4 H’s (Hypothermia, Hypoxia, Hypovolaemia, Hypo/Hyperkalaemia) and 4 T’s (Tension pneumothorax, Toxins, Thrombosis, Tamponade) was not applied adequately following Teegan’s cardiac arrest and that there was delay in recognition of surgical emphysema.

The 4 H’s & 4 T’s algorithm is taught as part of the Advance Life Support (ALS) course, a course run by the Resuscitation Council UK and aimed at those healthcare professionals who need skills in ALS as part of their clinical duties, to include doctors, paramedics and nurses working in acute care areas. All anaesthetists, and all doctors National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

11 April 2023

working in any environment where ALS would be required, to include obstetricians and senior members of the cardiac arrest team in this case, are expected to hold an up-to- date ALS certificate (or equivalent) and be across the latest guidance regarding resuscitation and cardiac arrest. Surgical emphysema is covered as part of this course.

Bilateral pneumothoraces occurring as it did in this case is rare and we note that both the Royal College of Anaesthetists (RCoA) and Association of Anaesthetists has stated that most anaesthetists will never encounter such a situation. NHS England’s National Patient Safety Team forms part of the Safe Anaesthesia Liasion Group (SALG), together with the RCoA and the Association of Anaesthetists, who will therefore be sharing the learnings from Teegan’s death across its network of relevant organisations. The national Regulation 28 Working Group will also be asking its regional members to share the learnings with their Integrated Care Boards (ICBs) for onward sharing to Trusts across England.

NHS England also consulted with the Resuscitation Council UK as part of its review of your Report. It should be noted that as a result of Teegan’s death, the Resuscitation Council reviewed the existing ALS guidance and materials, to include consultation of relevant experts. It was concluded that the ALS course did adequately cover the algorithm as well as cardiac arrest in pregnancy.

Trust investigation and Clinical Governance procedures

With regard to the concerns around the subsequent investigation into Teegan’s death, and the fact that there was no local investigation run in parallel to the Healthcare Safety Investigation Branch’s (HSIB’s) investigation, the NHS England National Patient Safety Team has recently launched a new Patient Safety Incident Response Framework (PSIRF), which ‘sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety’.

PSIRF states that “Where [an HSIB maternity] investigation is undertaken, a separate local patient safety learning response is not required. However, organisations should complete Duty of Candour requirements (ahead of handover to HSIB for further involvement of patients/families in the investigation).” We note from the Trust’s response that they have reviewed and strengthened the process for decision-making around the local investigation of incidents when incidents are referred to HSIB. Regarding your concerns around there being no temporary removal of the anaesthetic machine used in this case, or the downloading of information from the machine, we welcome RCoA’s commitment to update its guidance accordingly, to ensure responsibilities around this are made more explicit. We are also aware that the Care Quality Commission (CQC) will be issuing a response to your Report and will review their response and any recommendations made in due course.

I would also like to provide further assurances on national NHSE work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around preventable deaths are shared across the NHS at both a national and regional level and helps us pay close attention to any emerging trends that may require further review and action.

Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.

Dear Dr Henderson, RE: Regulation 28 Report to Prevent Future Deaths – Teegan BARNARD I am writing in response to the Regulation 28 Report issued following the Inquest into the death of Teegan Marie Barnard. Following Teegan’s death there has been intense focus to ensure that our maternity services are of the highest quality and are safe, and this is ongoing. Following the CQC visit to our maternity services in 2021 we have worked with the Maternity Safety Support Program (MSSP) and developed our Maternity Improvement Program (MIP) with their support. We have also worked hard to achieve the requirements of year 4 of the Clinical Negligence Scheme for Trusts (CNST). The Trust achieved 154 of the 155 requirements for our submission which is a huge achievement and is indicative of our focus on the safety of our maternity services. Our evidence was rigorously assessed by the internal auditors (BDO) and reviewed by the Local Maternity and Neonatal system governance lead and ICB panel. The Trust is also confident that the staff involved worked to the best of their abilities during this tragic event. In the Regulation 28 Report concerns are raised about the following issues.
1. The resuscitation algorithm (4H’s and 4T’s) for PEA arrest
2. Surgical emphysema
3. The Investigation following Teegan’s death.

4. Trust Clinical Governance procedures.

Our responses are outlined below but also address matters of factual accuracy.

(1) The resuscitation algorithm and (2) surgical emphysema You have raised concerns that although there are 8 contributory causes of Pulseless Electrical Activity (PEA) cardiac arrest (the 4H’s and 4 T’s), only one of these, tension pneumothorax, also causes a sudden inability to ventilate a patient; it was therefore determined that there was a delay in the team identifying this as the cause of the PEA arrest. Concern has also been raised that there was a delay in the team identifying surgical emphysema despite the presence of indicative signs. The Trust has been copied into the PFD response from the Royal College of Anaesthetists and UK Anaesthetic Association and note their comment that Bilateral pneumothoraces occurring on emergence from a general anaesthetic, especially one for surgery that did not include thoracotomy or thoracoscopy, is so rare that most anaesthetists will never encounter such a situation. However, the Trust recognises that for staff to perform optimally in extremely challenging situations such as maternal cardiac arrest appropriate training is essential. The Trust has therefore taken action to ensure all the appropriate members of the Multi-Disciplinary Team (MDT) have received the necessary training to be able to manage obstetric emergencies. An audit conducted in January 2023 demonstrates that over 90% of the obstetric, anaesthetic and midwifery staff that work within the labour ward environment across the entire organisation had received this MDT training. This reaches the stringent standards set for training by the Clinical Negligence Scheme for Trusts year 4 requirements. Of note maternal collapse has been a scenario within the training program since the beginning of the year and includes reference to the 4H’s and 4T’s.

There has been a strong commitment to learning from these events from the anaesthetic team as well as the wider MDT. The following points demonstrate that commitment:
a. Team learning at structured clinical governance events.
b. Inclusion of the management of tension pneumothorax in the regular SIM sessions for the anaesthetic trainees at St. Richard’s Hospital. This includes the significance of facial swelling and surgical emphysema. The trainers are planning SIM demonstrations of all the national anaesthetic regulation 28 notices and will play the recordings at teaching and clinical governance meetings.
c. The Trust’s anaesthetists have carefully reviewed The Royal College of Anaesthetists (RCA) guidance on the management of increased airway pressure for the ventilated patient which forms part of their Quick Reference Guide to Anaesthetic Emergencies Quick Reference Handbook (QRH) | The Association of Anaesthetists. Although the current handbook does not refer to surgical emphysema or tension pneumothorax in the management of increased airway pressures, we also note that, in their response to the PFD, the RCA and AA will share the learning that bilateral pneumothoraces can be a cause of failure to ventilate leading to cardiac arrest in the absence of trauma or thoracic surgery- through the SALG’s Patient Safety Update.

We believe that it is important that the evidence of , the obstetric anaesthetic expert witness at the inquest is considered as context to the findings of the Regulation 28 Report. verbatim comments reflect on the actions of the team and are shown below.

“I am satisfied that the medical team that responded and were working in the early hours of 10th September, their actions were reasonable and what was done, was done in a timely manner”.

“I am satisfied that the team were thinking what on earth could have caused this. There was anaphylaxis and or angioedema, as a combined diagnosis and they were thinking what has this patient had - a Caesarean section, Post-Partum Haemorrhage, therefore the H (Hypovolemia) due to massive blood loss was such they pre- emptively without any evidence of blood loss activated the major obstetrics haemorrhage plan, I think the 4 H’s and 4 T’s were being thought of.”

“Having read the statements and putting myself in the position of this team, although they were treating, it was not blind or obvious. I don’t think I would have stuck needles in the chest earlier. The opening of the abdomen was 2- fold; to release the gas but also to stop any bleeding. The most likely (cause of) deterioration of a woman who collapsed (on labour ward), looking as an obstetric anaesthetist, is that there has been some sort of catastrophic haemorrhage, because that is where the surgical activity has been, they opened the abdomen, released the gas and ROSC and there was no bleeding.”

(3) Investigation after Teegan’s Death The coroner raises the concern that there was no local investigation by the anaesthetic team before or after the HSIB report. However, initiating a local investigation in parallel to the HSIB investigation would have been contrary to national guidance. The Trust followed the recognised process for a maternal death and the incident was notified as a Serious Incident with a 72-hour report submitted at the appropriate time. This was followed by notification to HSIB. The incident fits the HSIB criteria, and the appropriate guidance was followed in response to the event. Of note, the guidance to Trusts from HSIB states: - Our maternity investigations have replaced a trusts' internal maternity serious incident investigations. We involve the trust and share the investigation reports as they are completed. Trusts continue to investigate maternity events that fall outside the specified criteria. (Information for trusts and staff — HSIB) The anaesthetic team cooperated fully with the HSIB investigation and responded comprehensively to the draft report. The outputs were discussed at length within the Trust in a number of forums and continues to be, including at the Intensive Care and Maternity Mortality and Morbidity meetings. This feedback was not fully reflected in the final report. Trust Clinical Governance Procedures Although the Trust followed existing national guidance, additional safeguards have been put in place to ensure our processes for investigating maternal deaths are robust. In the Regulation 28 notice, the Trust’s decision not to undertake a local investigation alongside the one initiated by HSIB is highlighted. At the inquest the Trust presented evidence demonstrating the very clear national guidance indicating that the HSIB investigation should replace the need for local scrutiny as described above. However, in response to the coroner’s concerns, the Trust has developed a draft SOP that defines the actions required when an HSIB investigation takes place

and includes consideration of the need or otherwise for a parallel local investigation. This will be ratified by the end of March 2023. As an organisation we are proud of our record of learning from deaths and working to improve preventable mortality. Improvements in mortality are both True North and Breakthrough Strategic Objectives at the trust – the latter with a specific focus on improving the recognition and management of the deteriorating patient. As an organisation, Learning from Deaths processes are well developed and scrutinised closely by our Quality Committee and Trust Board on a quarterly basis. In terms of wider learning in this specific case, senior representatives from the safety and clinical leadership teams, as well as the whole team of senior clinicians involved, attended the inquest and listened carefully throughout in this complex case. Factual accuracy We raise two matters in respect of the factual accuracy of the Regulation 28 Notice in respect of the following passage of text. ‘At or around 0545 with the enduring PEA cardiac arrest, an ongoing inability to ventilate by any means possible, and the continuing absence of chest movement and breath sounds on auscultation, the whole-body swelling was recognised to be due to surgical emphysema from a presumptive diagnosis of bilateral tension pneumothoraces. At or around 0548 hours bilateral thoracostomies were undertaken with return of spontaneous circulation.’ The Regulation 28 Report indicates that the PEA cardiac arrest began at 0510-0515 with a return of spontaneous circulation (ROSC) at 0548 which occurred with the treatment of the tension pneumothoraces. We believe the duration of the cardiac arrest and timing of the return of spontaneous circulation stated in the Regulation 28 report are inaccurate. Evidence provided by HSIB in their investigation report (p 27-28) indicates that ROSC occurred 13 minutes earlier at 0535. This is corroborated by the Defibrillator records that indicated that the cardiac arrest lasted 17 minutes. The evidence provided by the Trust based on the clinical record also indicated that ROSC occurred earlier than the coroner records, and when the abdomen was opened alleviating the intrabdominal pressure, prior the drainage of the tension pneumothoraces. Modern defibrillators provide real-time feedback on the quality of resuscitation, and it is of note that the analysis of the quality of CPR provided throughout the event was excellent with minimal interruptions. Summary In summary the Trust:
• Has developed and implemented a Maternity Improvement Program,
• Has achieved a very strong year 4 CNST submission.
• Has provided a robust program of training for the multidisciplinary group of staff working on our labour wards that prepares them for situations such as this.

• Has reviewed and strengthened processes for decision making about the local investigation of incidents referred to HSIB.

As an organisation we are committed to providing the highest quality maternity services and believe our commitment to the Maternity Improvement Program and achievements in governance, the Clinical Negligence Scheme for Trusts Year 4 submission and training for the multidisciplinary team demonstrate this. Finally, our thoughts and sympathy are with Teegan’s family; we recognise just how this has been the most traumatic event for them and on behalf of University Hospitals Sussex NHS FT, I want to extend my sincere condolences.