Source · Prevention of Future Deaths
Serena Nicholas
Ref: 2019-0381
Date: 14 Nov 2019
Coroner: Kevin McLoughlin
Area: West Yorkshire (East)
Responses identified: 0 / 1
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Disjointed management and lack of identified consultants for a high-risk pregnancy led to poor continuity of care. Critical information about fetal inactivity went unreported and unheeded, causing a delay in necessary intervention.
Date
14 Nov 2019
56-day deadline
21 Feb 2020 est.
Responses identified
0 of 1
Coroner's concerns
Disjointed management and lack of identified consultants for a high-risk pregnancy led to poor continuity of care. Critical information about fetal inactivity went unreported and unheeded, causing a delay in necessary intervention.
View full coroner's concerns
In the circumstances it is my statutory to report to you.
(1) The antenatal surveillance was largely carried out in Hull where the mother lived. She was seen by a variety of clinicians and at a late stage by a community midwife; despite the recognition that this was a pregnancy accompanied by clear risk factors: The absence of identified consultants responsible for the oversight of mother and baby's care in relation to diabetic and gynaecological aspects resulted in disjointed management_ the the the duty
(2) The tertiary centre where the C-section (and subsequent open heart surgery envisaged) were to take place, were not aware that the baby had been inactive for some days before the planned C-section (because the mother had not reported this and had not had contact with clinicians since the clinical appointment with a community midwife on 24/08/17). In consequence, a serious adverse development went unheeded until stumbled across on the eve Of the C section: In view of the history of the pregnancy continuity of care and close monitoring %f a high risk pregnancy ied t0 a situation in which the desirability of advancing the C-section by say, a week; was not recognised:
(1) The antenatal surveillance was largely carried out in Hull where the mother lived. She was seen by a variety of clinicians and at a late stage by a community midwife; despite the recognition that this was a pregnancy accompanied by clear risk factors: The absence of identified consultants responsible for the oversight of mother and baby's care in relation to diabetic and gynaecological aspects resulted in disjointed management_ the the the duty
(2) The tertiary centre where the C-section (and subsequent open heart surgery envisaged) were to take place, were not aware that the baby had been inactive for some days before the planned C-section (because the mother had not reported this and had not had contact with clinicians since the clinical appointment with a community midwife on 24/08/17). In consequence, a serious adverse development went unheeded until stumbled across on the eve Of the C section: In view of the history of the pregnancy continuity of care and close monitoring %f a high risk pregnancy ied t0 a situation in which the desirability of advancing the C-section by say, a week; was not recognised:
Report sections
Investigation and inquest
On 5th September 2017 an investigation was commenced into the death of Serena Janc Nicholas, a new born baby: The investigation concluded at the end of the Inquest on Monday 11th November 2019. The conclusion of Inquest was a narrative conclusion based upon the cause of death: 1(a) Intrauterine hypoxia, 1(b) Infant of a diabetic mother.
Circumstances of the death
Serena Jane Nicholas died on Wednesday 30th August 2017 at 0010 hours at Leeds General Infirmary; shortly after she was born by & category emergency Caesarean section performed at 2224 hours on 29th August 2017 . The pregnancy was complicated by virtue of (1) the mother's type 1 diabetic condition which was poorly controlled and (2) a truncus arteriosus fetal heart abnormality identified on a 20 week scan. When the mother attended the maternity unit at the tertiary centre evening before the planned C-section the following day; the fetal heart was found to be bradycardic; necessitating an immediate C-section. The baby was born in poor condition and died shortly afterwards_
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you andlor your organisation have the power to take such action
Copies sent to
2) linical Lead for Obstetrics, Leeds Teaching Hospitals; and t0 the Local Safeguarding Board Ihave also sent it to: eeds Teaching Hospitals; Coagsticnt Soooiceirics and GynaecologyHull; Consultant in Diabetes and Endocrinology Hull
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Report details
- Reference
- 2019-0381
- Date of report
- 14 November 2019
- Coroner
- Kevin McLoughlin
- Coroner area
- West Yorkshire (East)
Responses identified
Responses identified
0 of 1
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 21 Feb 2020 (estimated).
Sent to
- Hull University Teaching Hospitals NHS Trust