Jos Tartese-Joy

Coroner's concerns

AI summary

A combination of poor communication regarding high-risk pregnancy, lack of clear national guidance for CTG monitoring, and inadequate support and escalation policies for student midwives contributed to critical care gaps.

View full coroner's concerns

1_ The inquest heard evidence that the pregnancy was considered to be a high risk pregnancy . However the inquest heard that there was no nationally recognised way of flagging this within the notes: The trust have taken steps to be more explicit regarding this following Jos's death The inquest heard that the consequence of it not being explicit in communication or the notes was that his parents, the community midwife and the GP were unaware that the pregnancy was considered to be high risk
2. The inquest heard evidence that the consultant would not have advised that the pregnancy proceed beyond 41 weeks and that an induction of labour would be offered before his mother reached that date. Disjointed lines of communication with the community midwifery team and poor communication with his parents meant that were all unaware of that. As a consequence there was no plan for an induction of labour in place: The inquest heard that improvements had been made within the trust but poor lines of communication with community teams increased the risk of bpm: His very they death of a baby:
3. The evidence before the inquest was that the layout of maternity services at the trust meant that triage and delivery were on different floors. The trust did have steps in place to alleviate the challenges of this but the evidence was that it made it more difficult for oversight of patients. The inquest was told that this was not unusual across the NHS estate During the inquest it was accepted that CTG monitoring should have taken place at admission given that the pregnancy had been identified as high risk. If that had been satisfactory then it would have been appropriate to consider moving to regular monitoring: However that was not understood by the midwifery team as it was not explicit within the notes. The evidence was that clearer guidance and understanding nationally of when to use an admission CTG would reduce the risk to a baby during labour:
5. A student midwife was involved in the care-She followed the plan developed with an experienced midwife carefully: There was a lack of clarity regarding the escalation process she needed to follow if she identified problems: The evidence was that to avoid delay it was important that Trusts had clear escalation policies in place to appropriately support trainee midwives.
6. Jos's position on the centile chart had dropped in the last weeks of the pregnancy. The inquest heard that a clinician's perspective the guidance nationally was not to look at this but to look at the % weight change between the last weight and the new weight: In hindsight the way he tracked on the centile chart appeared to reflect the challenges the placenta was under and it was unclear the dropping picture on a centile chart was not a trigger for further checks: 7 , The antenatal visits occurred during the national lockdown and meant that his father was not at the antenatal visits or present for the initial examination on admission. This meant that Jos's father was not able to offer support and advocate for his mother during the pregnancy or admission.

Responses

1 respondent

Department of Health and Social Care Central Government

27 Jul 2022 PDF

Action Planned

DHSC notes that £52 million was announced to fast track the provision of online maternity records and NHSE has updated the maternity early warning score (NEWS2) chart and the updated element seeks to focus more attention on pregnancies at high-risk of fetal growth restriction. A standardised risk assessment tool that all trust should use at the onset of labour has been developed. (AI summary)

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Dear Ms Mutch, Thank you for your letter of 31 December 2021 tQ the Secretary of State for Health and Social Care. I am replying as Minister with responsibility for Primary Care and Patient Safety, and thank you for the additional time allowed. I would like to start by saying how very sorry I was to read the circumstances of the death baby Jos Tartese-Joy. I can appreciate how devastating his loss must be to his parents and all who loved him. It is vitally important that we take the learning from Jos' death to prevent future tragedies. Therefore, I have outlined below the action we are taking to prevent future deaths and address your concerns outlined in your letter. I note that it was found that there was no nationally recognised way offlagging in maternity notes that a pregnancy is considered high-risk. As a consequence, the community midwife and GP were not aware that the pregnancy was high-risk, and additionally the mother herself was not explicitly counselled about this. To improve women's access to maternity records, in June 2021 an additional £52 million was announced to fast track the provision of online maternity records. This backs the long- term plan commitment _to ensure everyone has access to their maternity notes and information electronically by 2023/24. An initial component of this was to create an agreed upon format for the notes both in terms of layout and content. This then has been taken to ensure "interoperability" - that is that the notes will be shared irrespective of clinical system.

Not only will this aid communication between healthcare professionals in different parts of the system. It will also allow women to have easy access to their maternity records to take full control of their pregnancy by having information and decisions about their care readily available. The current format of having handheld notes, hospital notes and GP records does not allow for this single combined source of information. I note that as this pregnancy was not documented or communicated as being high-risk and steps were not taken to create a safe plan for management of the pregnancy and delivery. This included no consultant review and consequently no decision for induction. The Maternity Transformation Programme led by NHSE, is committed to ensuring that all women have a Personalised Care and Support Plan in place, where risks are identified and discussed and where the principle offully informed consent is central. A Personalised Care and Support Plan is a series of facilitated conversations in which the person actively participates to explore the management of their health and well-being so that all considerations that might impact on safe care are accounted for. The agreed personalised care and support plan is a live document that should reflect new risks that are identified through the pregnancy and the decisions the woman makes about the care and support she wants to receive as she moves through her pregnancy. Those decisions should be informed by the discussions she has with her healthcare professional about the benefits and harms ofthe evidence-based options available. To improve communication and consistency of care for individuals, the NHSE are working with Trusts to roll out midwifery Continuity ofCarer. The Midwifery Continuity ofCarer model is a way ofdelivering maternity care so that women receive dedicated support from the same midwifery team throughout their pregnancy. This relationship between carer giver and receiver has been proven to lead to better outcomes and safety for woman and baby. Continuity of carer promotes closer relationships, with women more likely to disclose health concerns to a midwife they know and trust. Access may also be quicker, which means that care and treatment may be expedited. Therefore, this model of care improves communication between the women and healthcare professionals as women are receiving care from the same midwifery team throughout their pregnancy. In high-risk pregnancy, this model of care is particularly important. NHSE are working towards achieving the ambition that 75% of women from ethnic minorities and deprived areas receive continuity of carer by 2024. In October 2021, guidance 1 was published to support Local Maternity Systems and Integrated Care Systems to deliver continuity of carer at full scale, following an extensive process of listening to trusts, services and staff. 1 https://www.england.nhs.uk/publication/deliverinq-midwifery-continuity-of-carer-at-full-scale-guidance-21 22/

I note that an admission CTG was not used for this mother and that slowing of fetal growth while noted on scans was not acted on. Every maternity service in the NHS is actively implementing elements of the Saving Babies' Lives Care Bundle which comprises four key elements of care: reducing smoking in pregnancy; risk assessment and surveillance for fetal growth restriction; raising awareness of reduced fetal movement; and effective fetal monitoring during labour. The package was developed by groups brought together by NHS England, including midwives, obstetricians and representatives from stillbirth charities. Though the NHS already follows much of this best practice, this is the first time that guidance specifically for reducing the risk of stillbirth and early neonatal death has been brought together in a coherent package. Version two of the Saving Babies Lives Care Bundle has been produced to build on the achievements of the version one. This version aims to provide detailed information for providers and commissioners of maternity care on how to reduce perinatal mortality across England. It provides detailed information on risk assessment, prevention and surveillance of pregnancies at risk of fetal growth restriction. The updated element seeks to focus more attention on pregnancies at high-risk of fetal growth restriction and underlines the importance of properly training staff to carry out symphysis fund al height measurements. In addition, the bundle provides detailed information on effective fetal monitoring during labour such as trusts must be able to demonstrate that all qualified staff who care for women in labour are competent to interpret CTGs, always use a buddy system and escalate accordingly when concerns arise or risks develop. The bundle has developed a standardised risk assessment tool that all trust should use at the onset of labour. NHSE has published updated guidance in June 2022, "Supporting pregnant women using maternity services and access for parents of babies in neonatal units"2• This guidance provides detailed actions for NHS providers of maternity services to facilitate pregnant women having a support person of their choosing with them at all antenatal appointments and during labour and parents of babies on neonatal units having access to their babies. All maternity units should be allowing all partners and support people to attend all appointments and scans. Health and care settings should continue to maintain appropriate infection prevention and control processes. Related guidance will be kept under review and l:IPdated based on the latest clinical evidence where appropriate. 2 https://www.enqland.nhs.uk/coronavirus/wp-content/uploads/sites/5212020/12/C1659-using-maternity- services-and-access-for-parents-of-babies-in-neonatal-units-action-for-nhs-trusts-v2.pdf

Thank you for bringing these important issues and this tragic case to my attention. I hope this letter offers you reassurance that action is being taken in relation to the issue that you have highlighted. ..,._,....Ll,......~Ml"'lJWRIS MP PARLIAMENTARY UNDER SECRETARY OF STATE FOR PRIMARY CARE AND PATIENT SAFETY

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Investigation and inquest

On 17th December 2020 | commenced an investigation into the death of Jos Tartese-Joy: The investigation concluded on the 30t November 2021 and the conclusion was one of Narrative: Died from the complications of fetal vascular malperfusion, and a small placenta not identified until after death in a high risk pregnancy where an induction of labour had not been arranged before 41 weeks was reached and where the lack of a heart beat was not immediately identified as CTG monitoring was not used because the risk his birth presented at 41 weeks with the low PAPP-A was not recognised. The medical cause of death was 1a Severe hypoxic ischaemic encephalopathy 1b Perinatal asphyxia:

Circumstances of the death

Jos Tartese-Joy's Mother was identified as having a low PAPP-A level on the combined screening test: Her pregnancy was as a consequence a high risk pregnancy: His parents and the community team were not explicitly told that the pregnancy was high risk or that it would be advisable to induce labour if he was not born by 41 weeks A series of growth scans were undertaken at 28, 32, 36 and 39 weeks_ His centile growth dropped from the 97th Centile at 32 weeks to the 75th centile by the 39 week scan. This was not seen as a concern. Applying the national guidance. After the 39 week scan there was no obstetric review. No arrangements were made for an induction and his parents were unaware of the risk. The notes identified low PAPP-A but did not set out that the pregnancy was high risk: It was not identified or recognised that an admission CTG would be advisable when his mother went into labour: At 41 weeks his mother went into labour following a sweep at 40+6. She arrived at Stepping Hill Hospital at 21:10. At 21.25 the heart rate was recorded at 118 A CTG was not used as it was not recognised that her pregnancy was high risk and that she was at the point where an induction would have been advised: As a consequence the heart rate was not continuously monitored: mother was 5cm dilated: At 21.47 the midwife could not locate his heartbeat: At 21*49 that was escalated to a more experienced midwife who could not find a heartbeat: At about 21.54 it was escalated to the registrar: His mother was transferred to the delivery suite and at 21:56 the registrar scanned for Jos' heart and two flickers were seen. The Registrar moved to category section. Jos was born by emergency section at 22:10. He was in poor condition with no heart beat or respiratory effort and significant meconium was present; He was resuscitated and a heart rate was palpable after approximately 18 minutes_ He was moved to Royal Oldham Hospital where it was confirmed he had sustained severe brain damage as consequence of hypoxia. He died at Royal Oldham Hospital on 15th December 2020. Post-mortem examination confirmed that the placenta was small and there was fetal vascular malperfusion of the placenta which significantly impacted placental function

Action should be taken

In my opinion action should be taken to prevent future deaths and believe you have the power to take such action_

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