Source · Prevention of Future Deaths
Kaiya Campbell
Ref: 2019-0324
Date: 30 Sep 2019
Coroner: Alison Mutch
Area: Manchester (South)
0 responses identified · 2 indexed addressees
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AI-generated concerns summaryThe coroner noted a gap in GP records regarding prescribed anticonvulsant medication. Clinical staff at GP and midwifery appointments did not identify the need for urgent neurology guidance concerning medication for an epileptic mother, leading to a routine rather than high-risk consultant appointment.
Date
30 Sep 2019
56-day deadline
3 Jan 2020 est.
estimated from the Judiciary.uk publication date
Responses identified
0 of 2
Coroner's concerns
The coroner noted a gap in GP records regarding prescribed anticonvulsant medication. Clinical staff at GP and midwifery appointments did not identify the need for urgent neurology guidance concerning medication for an epileptic mother, leading to a routine rather than high-risk consultant appointment.
View full coroner's concerns
The inquest heard that Kaiya's mother was epileptic and prescribed anticonvulsant medication: She had been prescribed this for a number of years and fell within the guidance for management criteria; Her GP practice did not have any records of recent medication being prescribed although there was clear evidence given to the inquest of regular request for repeat prescriptions being requested and dispensed by a local pharmacy. It was not possible to establish at the inquest why this gap in records existed; When Kaiya's mother attended at her GP appointment and her midwifery booking-in appointment; the clinical staff involved did not appreciate the need to seek urgent guidance themselves from the neurology department regarding ongoing prescribing to reduce the risk of foetal abnormalities to the unborn child; Despite her mother falling into the high risk category, a routine consultant appointment was offered: There was no clarity as to how this need was not picked up at the time_
Report sections
Investigation and inquest
On 1st October 2018 commenced an investigation into the death of Kaiya Campbell. The investigation concluded on the gth September 2019 and the conclusion was one of Narrative: Died from the complications of extreme prematurity following necessary medical intervention: The medical cause of death was 1a) Extreme prematurity 19 weeks 6 days gestation
Circumstances of the death
Kaiya Sonia Campbell's mother had extensive bleeding and early rupture of the membranes. Following medical intervention Kaiya was bor at Tameside General Hospital on 28th September 2019. She lived briefly but given her extreme prematurity died soon after the birth:
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:
Similar PFD reports
Report details
- Reference
- 2019-0324
- Date of report
- 30 September 2019
- Coroner
- Alison Mutch
- Coroner area
- Manchester (South)
Responses identified
Responses identified
0 of 2
2 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 3 Jan 2020 (estimated from the Judiciary.uk publication date).
Sent to
- King Street Medical Practice
- Tameside Clinical Commissioning Group