Source · Prevention of Future Deaths

Enric Elliott

Ref: 2018-0300 Date: 14 Aug 2018 Coroner: Fiona Wilcox Area: London Inner (West) Responses identified: 1 / 1 View PDF

Vulnerable young mothers who book late for maternity care are often excluded from the Family Nurse Partnership due to rigid gestation limits, despite late booking indicating increased risk.

Date 14 Aug 2018

56-day deadline 21 Mar 2019 est.

Responses identified 1 of 1

Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

Vulnerable young mothers who book late for maternity care are often excluded from the Family Nurse Partnership due to rigid gestation limits, despite late booking indicating increased risk.

View full coroner's concerns

That young women who book later than 28 weeks can only be considered for referral to the Family Nurse Partnership, despite the fact that late booking is often a further risk factor indicating increased vulnerability to the mother and young child. That late bookers may still be debarred from referral on the basis of gestation.

Responses

1 respondent

Whittington Health NHS Trust NHS / Health Body

27 Sep 2018 PDF

Action Planned

The Trust acknowledges concerns about referral criteria for the Family Nurse Partnership (FNP) programme and is working with the national FNP team to test the impact on programme outcomes for referrals over 28 weeks gestation as part of the ADAPT work programme. (AI summary)

View full response

Dear Dr Wilcox Ref: PFD 14-8-18 Whittington Health NHS Trust response to Regulation 28 Report to Prevent Future Deaths dated 14 August 2018. Thank you for raising your concerns regarding the referral criteria for vulnerable young people into the Family Nurse Partnership (FNP) programme: We recognise the importance of the issues you have raised and we are grateful to you for bringing your concerns to our attention_ As required under our to respond to your report dated 14 August 2018, we hereby detail actions taken and those proposed to be taken in reponse to the concerns you have raised in your report: These being: That young women who book later than 28 weeks [gestation] can [not] only be considered for referral to the Family Nurse Partnership, despite the fact that late booking is often a further risk factor indicating increased vulnerability to the mother and young child: That late bookers may still be debarred from referral on the basis of gestation: That such vulnerable mothers are thus excluded from the support offered by the Family Nurse Paitnership arid ihius tneir child be at increased risk 0f death in infancy: That the increased risk to mothers and babies of late booking does not appear to be recognised as a positive reason supporting referral to the Family Nurse Partnership. The FNP programme is an evidence-based intensive home visiting programme delivered through a national license for practice to which local providers of the programme are required to adhere. The programme; which is voluntary for clients to join, includes a number of Core Model Elements that prescribe how the programme should be delivered to ensure continuous high clinical quality. The programme is based on over 30 of rigorous evaluation and is built upon the theoretical basis of attachment; self-efficacy and human ecology: The FNP programme aims to support young mothers to have a healthy pregnancy; improve their childs health and development; and plan their own futures and achieve their aspirations. UCLPartners Helping local people AUCH4 Acaclemic Healtn Scicice Parinersnip live longer healthier Chair: Steve Hitchins Chief Executive: Siobhan Harrington duty years

Following your PFD, our Trust FNP lead has met with both our local commissioners and the national FNP Team to agree how we can further implement local flexability to the delivery of the FNP programme_ In agreement with the national team, we have made a change to our referral criteria so that mothers up to the age of 25 years old are now accepted into the local programme_ As a result of your PFD, we have agreed that we can consider with the London FNP team, on a case by case basis, accepting referrals for mothers who are willinging to engage with the FNP programme when are referred after 28 weeks gestation, particularly when there are a further range of needs, vulnerabilities and issues associated with concealed pregancy. The national team have clarified with us that one f the Core Model Elements of the FNP programme is that clients should be recruited to the programme before the 28" week of pregnancy: This is because the therapeutic relationship takes some time to form; and is the basis for the important work the nurse and client undertake together; including the importance of attachment; early infant development and the promotion of good health and wellbeing during the antenatal period, alongside usual antenatal services. The FNP programme sets a further goal that 60% of all clients should be recruited by the 16lh week in pregnancy; giving such an important window of opportunity for the nurse and client to work towards the important outcomes within the programme aims as set out above_ When a mother is not able or willing to join the FNP programme , the Trust's Health Visiting service will undertake a full assessment of need based on the Healthly Child Programme, and will ensure that our enhanced Health Visiting programmes Universal Plus and Universal Partnership Plus are activley offered to families with additional needs and vulnerabilities These enhanced service offers, whilst not part of the FNP programme, do provide an opportunity to work collaborativley with young and vulnerable mothers and their children delivering similar evidenced based interventions to those offered through the FNP programme. The national FNP team have informed us that the issues raised by your PFD are pertinent because have taken the opportunity for evidence-based adaptation and testing to explore offering FNP to mothers later in gestation in certain circumstances, and to test the impact of this_ The national FNP team are undertaking a range of research-based programmes that call ADAPT (Accelerated Design and Programme Testing) to test some local personalisation of the programme As part of the ADAPT work programme, the team are testing relaxing the existing 28 week gestation threshold for women; particularly with concealed pregnacies This testing will take some time to ensure rigorous evaluation and they anticipate to report on this and other elements of the ADAPT project next year. We,as a local provider of the FNP programme, will continue to work with the national FNP team to test the impact on programme outcomes for any referrals that happen over 28 weeks gestation; and we will work with the national team to add to the considerable evidenced base of the national FNP programme_

Report sections

Investigation and inquest

On the 18h July 2018, evidence was heard touching the death of Enric Albert Alejandro Elliott: Enric had died on the 24n November 2017 in St Mary's Hospital after being found collapsed and then resuscitated at his home address on the 20h November 2018. He was just 5 months old at the time of his death. The findings of the court were as follows: Medical Cause of Death 1 (a) Diffuse hypoxic-ischaemic brain injury (aka hypoxic-ischaemic encephalopathy) (b) Sudden unexpected death in infancy How, when and where the deceased came by his death: On 20/11/2017, Enric was found not breathing by his mother at his home address. LAS was called and he was resuscitated at the scene. Return of spontaneous circulation was achieved and he was transferred to hospital. Despite all treatment he died on 24/11/2017 at St Mary's Hospital of brain injury due to the cardiac arrest The cause of the initial arrest is unknown: He was well cared for and there were no suspicious circumstances. Conclusion of the Coroner as to the death: Natural Causes Circumstances of the Death Evidence taken at the inquest from Head of Safeguarding at Whittington Health was that Enric's mother had not been referred to Family Nurse Partnership because she had booked one week too late at 29 weeks gestation, referrals only being accepted until 28 weeks gestation , despite Enric's mother's young age and psychosocial vulnerabilities. If such a referral had been made it is likely that Enric's mother would have agreed and accepted the extensive support provided by the Family Nurse partnership. It could not be said that such support would have changed the outcome in this case and in fact Enric's mother was well for her child, despite her difficult circumstances. Since Enric's death the rules around gestation and referral have become more flexible and some mothers who book after 28 weeks may be referred: the caring

Concerns of the Coroner: That young women who book later than 28 weeks can only be considered for referral to the Family Nurse Partnership, despite the fact that late booking is often a further risk factor indicating increased vulnerability to the mother and young child. That late bookers may still be debarred from referral on the basis of gestation. That such vulnerable mothers are thus excluded from the support offered by the Family Nurse Partnership and thus their child be at increased risk of death in infancy: That the increased risk to mothers and babies of late booking does not appear to be recognised as a positive reason supporting referral to the Family Nurse partnership.

Action should be taken

In my opinion action should be taken to prevent future deaths and believe you [ANDIOR your organisation] have the power to take such action: It is for each addressee to respond to matters relevant to them_

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2018-0300
Date of report: 14 August 2018
Coroner: Fiona Wilcox
Coroner area: London Inner (West)

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 21 Mar 2019 (estimated).

Sent to

Whittington Health NHS Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.