Source · Prevention of Future Deaths

Louie Bradley

Ref: 2018-0261 Date: 21 Aug 2018 Coroner: John Pollard Area: Manchester (West) Responses identified: 2 / 1 View PDF

Midwives' advice encourages unsafe co-sleeping practices for fatigued mothers, risking infant death. Furthermore, critical patient information was frequently omitted from standard Trust documentation.

Date 21 Aug 2018

56-day deadline 20 Nov 2018 est.

Responses identified 2 of 1

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

Coroner's concerns

AI summary

View full coroner's concerns

1. The midwives at your Hospital gave evidence that they still advise breastfeeding in bed whilst lying side-by-side with the baby even if no-one else is present and the mother is obviously fatigued, this leads to inadvertent co-sleeping and as in this case can lead to death.
2. The standard Trust issue documentation was not (properly) completed with the omission of vital information such as mother’s name, GP Practice, address etc.; similarly advice allegedly given to patient was not documented.

Responses

2 respondents

Bolton NHS Trust NHS / Health Body

16 Oct 2018 PDF

Action Taken

Following concerns about mothers bed sharing with babies while breastfeeding, the Trust has reviewed concerns and taken further actions in addition to those identified in the Serious Incident Report. An action plan with supporting documentation details improvements regarding safe sleeping advice and documentation. (AI summary)

View full response

Dear Mr Pollard Re: Louie Francis Bradley Re: Regulation 28 Report to Prevent Future Deaths am writing in response to your Regulation 28 Report to Prevent Future Deaths, issued following the Inquest touching the death of Louis Francis Bradley on 15 August 2018. May take this opportunity to extend my deepest sympathy to Mr & Mrs Bradley for their loss and appreciate this will remain a very difficult time for them and their family: am now in a position to respond to your concerns as outlined in Section 5 of your report. Section 5 (1) and (2) am aware that during the course of establishing how Louise came about his death you raised concerns about mothers choosing to bed share with their babies while breastfeeding Following receipt of the Regulation 28 Report, requested that the Head of Midwifery/Divisional Nurse Director and the Governance Lead for the Families Division review your concerns and would Iike to assure you that further actions in addition to the actions identified in the Serious Incident Report have been taken: have attached an Action Plan which details a number of improvements together with the relevant documentation which is in now place for your reference_ hope that my response has provided you and the family with the assurance that the Trust has taken appropriate action regarding safe sleeping advice and documentation Please do not hesitate to contact me in the event you require any further assistance Yours eincerely abe Zes Dr Jackie Bene Chief Executive Encl: Action Plan with supporting documentation

Bolton NHS Trust Action Plan NHS / Health Body

PDF

Noted

This document appears to be an action plan related to the previous response, but it is not possible to summarise the actions without the context of the coroner's concerns. (AI summary)

View full response

1 2 1I 3 3 L 5 1 5 7 L H H 2 2 { #L 2 { HH 2 [ HL L # 4 H 3 H 1 2 1 I W 1 2 1 2 2 ] 8 1 8 Il 1 3 Jb 3 3 3 1 li ] J Il J4 I 1 ] 8 ] [ 6 [ 1 1 I 4 [ J L 3 39 1 1 [ 2 H 1 1 8 5 JW 3 1 0 H UL 8 3 1 I L 1 2 0 2 I { 2

N W 1 8 W 3 1 2 08 1 1 ! 1 8 1 2 6 1 [ 2 1 9 g 5 0 1 2 L 1 ! 2 1 2 1 1 8 { 3 1 8 1 [ E 6 2 8 L 1 8 1 3 1 8 1 8 8 I 8 1 1 8 2 8 5 2 1 L 1 28 1 8 2 Eg Ee H# 2 1 8 3 8 Ji 1 1 1 5" 8 1 1 ]

3 # 8 4 7 1 31 1 5 1 8 0 2 1 U 1 4 I 4 1 H 9 8I 8 : : 3 9 L 8 1 Ja 9 L 1

3 3 3 3 3 3 J 8 ] I 8 ] W JV 8 3 8 9 2 F H 1 1 ] 7 9 1 4 8 9 9 4 3 2 1 81 1 2 1 1L ] 9 H 1 [ 2 9 1 1 L 2 8 9 9 1 g 8 1 1 5 2 3 2 1 5 17 1 2 L 3 11 1 W [ 2 4 1 8 9 IJ 8 8 1 L Vi 3 1 W DI VLH 1

9 3 3

6 6 6 6 = 0 MH 2 [ 8 1 6 8 1l 8 3 8 0{ 1 H 3 VL W H 1 g 8 ] 6 2 V 1 L 2 L 2 J1 8 1 3 1 1 [ } [ N 1 V 0 [ | 3 1 2 8 2 g 8 8 1 [ 5 1 HM L K 1 8 1 3 1 1 1 8 1 3 2 3 14 1 1 1 3 6 1 1 33 1 [ 1 1 1 1 8 2 8 [

[ 8 8 [ 1 8 8 8 2 8 8 8 8 L 1 1 2 HI 1 2 1 8 | 1 IH 3 8 L 1 5 M 1 1 5 m g 2 1 8 6 6 6 8 W 6 8 L 3 J V 1 J 1 8 3 0 8 1 8 L 3 1 L 3 ll 8 8 1 3 8 2 e 8 0 8 3

Report sections

Investigation and inquest

On the 31st August 2017 I commenced an investigation into the death of Louie Francis Bradley, aged 1 day. The investigation concluded at the end of the inquest on the 15th August 2018. The conclusion of the inquest was that he died from Sudden and Unexpected Neo-Natal Death of an Infant born at 42 weeks with widespread pneumonia. The narrative conclusion was as follows:-

On the 27th August 2017 Louis Francis Bradley died as a result of a combination of Natural Disease (undiagnosed Bronchopneumonia and the symptoms of the common cold) and an accidental obstruction of his airways whilst in bed following a breastfeed.

Circumstances of the death

He died following breast feeding in bed with his mother when mother fell asleep.

Inquest conclusion

-

On the 27th August 2017 Louis Francis Bradley died as a result of a combination of Natural Disease (undiagnosed Bronchopneumonia and the symptoms of the common cold) and an accidental obstruction of his airways whilst in bed following a breastfeed.

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2018-0261
Date of report: 21 August 2018
Coroner: John Pollard
Coroner area: Manchester (West)

Responses identified

Responses identified 2 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 20 Nov 2018 (estimated).

Sent to

Royal Bolton Hospitals NHS Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.