Source · Prevention of Future Deaths

Rafe Angelo

Ref: 2017-0421 Date: 27 Nov 2017 Coroner: Karen Harold Area: Portsmouth & South East Hampshire Responses identified: 2 / 3 View PDF

Antenatal checks were insufficient for detecting growth restriction, lacked clear guidance for post-bradycardic episodes, and birthing centers lacked CTG. Transfer policies were unclear, and communication protocols between staff and ambulance services were inconsistent.

Date 27 Nov 2017

56-day deadline 24 Apr 2018 est.

Responses identified 2 of 3

Child Death (from 2015) Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

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In the circumstances it is my statutory to report to you: To assist enclose a copy of my written findings of fact and conclusions with leading paragraphs in bola. will refer to relevant paragraphs below but also suggest the whole judgment should be read to understand context of each concern; Ante natal checks carried out to detect SGA babies The risk assessment of Ms Angelo followed NICE guidelines at the time but remain concerned that no simple weight check is done to check maternal BMI and that GROW charts only pick up 50-55% of cases where growth restriction occurs_ more holistic view is needed of risk factors especially in last few weeks weeks onwards as this is when the major growth spurt takes place and monitoring closely when additional factors surface is advisable e.g. as in this case cannabis and anti-depressant use were disclosed during this crucial period. [33; 36; 37; 97; 117; 125; 167; 168]
2. Guidance needed post a bradycardic episode in labour After the bradycardic episode at 11:10 when the maternal position was changed, the recovery rate afterwards was higher than the previous baseline from 130-135 to 150+ thereafter_ This was still within "normal" range but it was accepted during the inquest that this could be abnormal and no guidance currently exists_ [118; 127; 128; 172] Availability and use of CTG at birthing centres CTG is not currently available in birthing centres ad should be considered in emergency situations such as this case especially if it Is not possible to transport the mother to hospital this Baby floppy very duty - the The from

[54, 98, 115-116, 118, 123, 134, 169-170, 182-183, 186, 200] Clarification of what would be classified as urgentinon-urgent or an emergency in the transfer policy The SIRI investigation highlighted that the instruction given to the maternity support worker was not clear about what category of transfer was required:. That is why the maternity service has purchased cordless handsets 50 that the midwife giving clinical care can contact SCAS directly rather than delegate the task The request is now made in birthing room s0 the mother can hear In evidence indicated that a transfer for epidural would be regarded as an emergency requiring an ambulance within one hour. This was different from] who felt the transfer would be classified as non-urgent: A discussion took place in court as SCAS representatives believed the response time was 30 minutes (para 151). This needs to be clarified between the Trust and SCAS and then clearly communicaled to all staff. Discretion of SCAS call handlers if time critical factors are mentioned but birthing centre staff do not actually request a time critical transfer is requested: [74-76, 132, 190, 191, 194]
6. Consider where the "Use of Standby Points" policy needs to be refreshed to make It clearer and more consistent The call to SCAS from the Blake lasted 4 minutes, 57 seconds and the fact the baby was in distress was not mentioned until 3 minutes , 53 seconds. responding ambulance was despatched at 15.46 and shortly afterwards the paramedic contacted control centre and indicated that it was appreciated the call was an emergency but could thev use the facilities first: No questions were asked and permission was given accepted that if this had been designated as a time critical call, it may have made a difference as to whether permission t0 use facilities would have been given and asking questions or not would depend on the person taking the call from the paramedic. There was a policy to cover this sort of request "Use of Standby Points" but it was accepted the policy is broad and somewhat vague s0 it was accepted that it would very much depend on the person taking the call to probe further [74] Guidance for midwives about auscultation practice during transfer to hospital [14, 48, 57 , 115, 120] Ensuring an account is created for all staff authorised to use CTG equipment s0 that settings and prints can be run [49, 65, 174]
9. Poor technical quality of the CTG readings at a crucial time especially given this was the first trace In am emergency situation [66, 116, 123, 175]
10. Recording all requests to transfer to hospital in notes and active consideration by midwives Although it was found that the notes in this case were very good, nevertheless there 121 , the The very was a finding that the mother had made several requests to go to hospital mainly for pain relief during the course of the morning and early afternoon yet none of these requests were recorded in the notes or acknowedged by the midwife. In this case, it was agreed by several witnesses including] that if an earlier transfer had happened this would have led to CTG monitoring and picking Up the earlier declerations_ [23-26, 30-31, 45, 53, 58, 177-183}
11. System of relaying information from birthing centre staff to hospital staff in an emergency situation This was a critical part of this case and as such needs further consideration of both the past and current systems and whether appropriate training has been given; whether it is currently working; and whether refresher training is needed. [119, 123, 131, 195-202]

Responses

2 respondents

Department of Health Central Government

27 Nov 2017 PDF

Noted

The Department of Health outlines national initiatives for safer maternity care, including the Healthcare Safety Investigations Branch, and highlights existing NICE guidelines on intrapartum care. They note that Portsmouth Hospitals NHS Trust is implementing an action plan. (AI summary)

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From Jackie Doyle Price MP Department Parliamentary Under Secretary of State for Mental Health and Inequalities of Health 39 Victoria Street London SW1H OEU 020 7210 4850 PFD-1109508 1 8 JAN2OI8 Ms Karen Harrold HM Assistant Coroner Portsmouth and South East Hampshire The Coroner' s Court 1 Guildhall Square Portsmouth POI 2GJ Jea A Aereld Thank you for the Regulation 28 Report to prevent future deaths dated 27 November 2017 following the inquest into the death of baby Rafe Robbie Angelo. Firstly, I would like to say extremely saddened [ was to read of the circumstances surrounding baby Rafe's death Please pass my condolences to his family and loved ones. I appreciate this must be a very difficult time for them: [ would like to say that we are committed to making the NHS the safest place in the world to give birth: In November 2017, we launched Safer Maternity Care: progress and next stepsl which set out progress against the delivery of the national maternity ambition to halve the rates of stillbirths, neonatal and maternal deaths and brain injuries that occur during Or soon after birth by 2025. To make sure progress is made quickly, we also set out an expectation of a 20 percent reduction by 2020. Safer Maternity Care sets out a number of steps to make sure we are all we can to prevent serious incidents in maternity services. This includes developing the role of the Healthcare Safety Investigations Branch? (HSIB) to standardise investigations of cases of severe brain injury, intrapartum stillbirths, early neonatal deaths and WWW gov uklgovemmentluploads/system/uploadslattachment_data/file/662969/Safer_maternity care progress_and next_steps pdf https ILwww hsiborgukl how doing

maternal deaths in England so that the NHS learns as quickly as possible from what went wrong and shares this learning as widely as possible to prevent future tragedies As well as providing comprehensive final reports for each case it investigates, the HSIB will publish themed reports drawing together overarching themes and points of learning from multiple investigations and making appropriate recommendations for system bodies to act on these findings. The new investigative approach will begin in a single region from April and will continue to roll out to all areas of England by April 2019. When fully rolled out; the HSIB will investigate around 1,000 cases a year with the expectation that the learning from investigations will spur system improvements leading to fewer deaths and injuries in the future: hope this offers assurance that we are committed to learning from deaths and taking action to prevent future tragedies in maternity care The Regulation 28 Report details a number of concerns, some of which are for local resolution and some that require consideration at a national level. My officials have made enquiries with a range of bodies including NHS England, the National Institute for Health and Care Excellence (NICE), and the Royal College of Obstetricians and Gynaecologists (RCOG) in the preparation of this reply and I will address each of the national level concerns in turn_ Antenatal checks carried out to detect small-for-gestational-age (SGA) babies You raise a matter of concern around maternal weight checks and the effectiveness of GROW charts in identifying cases of fetal growth restriction: You indicate that in this case, the risk assessment followed NICE guidelines at the time: As you will know, NICE'$ current guideline on Antenatal care for uncomplicated pregnancies (CG62'), published in March 2008 and based on best available evidence; includes recommendations regarding smoking, such as the risk of having baby with low birthweight (section 1.3.10.2), prescribed medicines (section
1.3.4.1), and cannabis (section 1.3.11.1). I am advised the guideline is currently updated and the update is due to be published in July 2020. WWW nice Org uklguidance/cg62 being

Department of Health Iam further advised that NICE is currently in the process of 'undertaking review of all its obstetric-related guidelines, which means that NICE has recently considered (or will be considering) new, relevant evidence and how it might impact on existing recommendations. NICE advises that it believes this review will cover all the relevant areas raised within the Regulation 28 Report. You will be further interested to know that the RCOG published a guideline in March 2013 on The Investigation and Management of the Small-for-Gestational-Age Fetus'. Iam advised that revision of the guideline is currently in the early stages of development; Furthermore, I am advised that NHS England recommends the use of Saving Babies- Lives: A Care Bundle for Reducing Stillbirths , which provides interventions for the risk assessment and surveillance for fetal growth restriction during pregnancy: A number of recommendations are made including: using a supplied algorithm or RCOG algorithm to aid decision-making on classification of risk; and corresponding screening and surveillance of all pregnancies; employing serial ultrasound scans to assess fetal growth for women at high risk of fetal growth restriction and estimating fetal weight derived from ultrasound measurements recorded on a chart; using antenatal symphysis fundal height charts to assess fetal growth for risk women; by clinicians trained in their use. All staff must be competent in measuring symphysis fundal height with a tape measure; plotting measurements on charts, interpreting appropriately and referring when indicated; ongoing audit of SGA birth rates, with reporting of antenatal detection rate, false positive rate and false negative rate on local dashboard (or similar); and ongoing case-note audit of selected cases of SGA not detected antenatally to identify barriers: The Investigation and Management of the Small-for-Gestational-Age Fetus wwwrcogorguklenlguidelines-research-serviceslguidelineslgtg31L Saving Babies' Lives: A Care Bundle for Reducing Stillbirth, W england nhs uklmat transformation/saving_babies _ low-

Guidance needed bradycardic episode in labour NICE guidance on Intrapartum care for healthy women and babies [CG190]6, was published in December 2014 and updated in February 2017. It includes recommendations relating to post bradycardic episode in labour: This is covered in Table 10 and subsequent recommendations including sections 1.10.15
1.10.33. You will wish to note that the fetal monitoring section of the guideline has been extensively updated since baby Rafe's death in 2014. Availability and use of cardiotocograph (CTG) at birthing centres Birth centres are accessed by women assessed to be low risk for complications CTG is not made available in birth centres because NICE guidance clearly states that CTG must not be offered to women at low risk of complications in established labour (Intrapartum care for healthy women and babies NICE Guidance, CG190, section
1.10.1). There is no evidence that the use of CTG in low-risk women improves the fetal/neonatal outcome: Iam further advised that the evidence base shows that CTGs are not recommended in a low-risk population because have a high false positive rate, generating much unnecessary interventions such as an instrumental delivery or a caesarean section. The evidence suggests that intermittent auscultation in a low-risk population appears to be equally effective at identifying problems but does not cause as much intervention: As previously advised, NICE is currently in the process of undertaking a review of all its obstetric-related guidelines, including CG190, which means that NICE has recently considered (or will be considering) new relevant evidence and it might impact on existing recommendations Guidance for midwives about auscultation practice during transfer to hospital Risk assessment is an integral part of a midwife'$ role and identified risk will trigger transfer to an obstetric unit as recommended by NICE guidance (Intrapartum care for healthy women and babies, CG19O, section 1.6). Iam advised by NICE that it has noted the concerns in the Regulation 28 Report about a lack of guidance for midwives about auscultation practice during transfer to hospital and consideration of this concern will be given when next reviewing CG190. https;ILwww nice org uklguidancelcgl90 post they how

Department of Health Saving Babies' Lives: A Care Bundle for Reducing Stillbirth includes recommendations for effective fetal monitoring during labour that aim to ensure competency in CTG interpretation and auscultation These include: all staff who care for women in labour to undertake and pass an annual training and competency assessment on CTG interpretation and use of auscultation. No member of staff should care for women in a birth setting without evidence of competence within the year; and buddy in place for review of CTG interpretation, with protocol for escalation if concerns are raised. All staff to be trained in a review system and escalation protocol. Recording all requests to transfer to hospital in notes and active consideration by midwives NICE guideline CG190 (Intrapartum care for healthy women and babies, section 1.6) recommends general principles for the transfer of care during labour; including how care should be given during the transfer. Iam advised that clinical observations are implied to continue despite no specific reference. As before; NICE is currently in the process of undertaking a review of all its obstetric-related guidelines, including CG19O. [ hope this information is helpful You may also wish to know that NICE is currently developing new guidance on intrapartum care for high-risk women"_ which covers intrapartum care for women with an SGA baby (fetal monitoring), interpretation of CTG traces, and transfer of care (for example, via the ambulance service) NICE expects to publish the guidance in March 2019. In terms of the local response, I am aware that the Portsmouth Hospitals NHS Trust is working to implement an action plan in response to the issues raised by this incident and oversight is being provided by NHS Improvement I will not repeat the Trust' $ response here but trust that it answers the concerns you have raised at a local level. www nice org uklguidance indevelopmentgid-cgwave0613 last system

[ hope this reply is helpful Thank you for bringing the circumstances of baby Rafe Angelo's death to our attention. ad & ga T repo+ Jouue JACKIE DOYLE-PRICE Jey -

South Central Ambulance Service NHS Trust NHS / Health Body

8 Feb 2018 PDF

Action Taken

The ambulance service has updated its SOP so that any Health Care Professional requesting an emergency/immediate inter-facility transfer will be asked "Do you require a Time Critical Transfer?" The policy regarding the use of standby points is also being updated. (AI summary)

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Dear Mrs Harold Further to your report dated 27ih November 2017 following the inquest into the sad death of Rafe Robbie Angelo, please now find our response to your concerns below: 'Discretion of SCAS call handlers if time critical factors are mentioned but birthing centre staff do not actually request a time critical transfer is requested:" As you are aware, the Standard Operating Procedure (SOP) in place at the time of the request from Blake Birthing Centre was dependent on the Midwife making the call and requesting a "time critical transfer" (TCT) This request would invoke the TCT SOP and prioritise the call s0 that it will take priority over any other incoming call to the Emergency Operations centre. This priority of call would also mean that a Dispatcher would divert a resource away from another Category call in the community (e.g: paediatric respiratory cardiac arrest) to respond to this event should there be no other suitable resource available_ Following your report; we have reviewed the SOP ad updated it so that any Health Care Professional (HCP) requesting an Inter-facility transfer (i.e. Hospital or Birthing Unit) who asks for an emergency immediate response will now be asked "Do you require a Time Critical Transfer?" Due to the known risks associated with obstetric cases, Midwives will be asked whether the case is time critical when they call from a patient's home as well as a standalone birthing centre. If the HCP answers positively then the Emergency Call Taker (ECT) will prioritise the call the TCT pathway and will process the call as a Category response. This questioning will act as a prompt to the HCP and ensure that where patient is for example in hospital where treatment cannot be given for their condition, such as requiring transfer to Hyper-acute stroke unit (HASU), the resource will be allocated in line with their condition. If the request is being made through a third party, they will be instructed to ask the HCP directly if a TCT is required: The new Standard Operating Procedure and Clinical Directive has been sent to all staff in the Emergency Operations Centre. A mail drop will also be issued to all Emergency Departments and Birthing units across the South Central Area to remind all HCP's of the correct process to request a Time critical transfer. 'Clarification of what would be classified as urgent non-urgent or an emergency in the transfer policy' Itis not possible to provide an exhaustive list of diagnoses and circumstances that would or would not be classified as a time critical transfer due to the complex nature of medical care. However; as above, the ECT who is taking the call will now be speaking to clinician and will ask the Registered Headquarters: and 8 Talisman Business Centre, Talisman Road, Bicester 0X26 6HR using

clinician whether the case is time critical: This is designed to ensure that the appropriate response is provided to the patient. As you will recall, the issue in the index case was that neither party involved in the call was clinically trained; with one party also unfamiliar with the TCT process: The Trust has provided the below list of diagnoses &d circumstances as a guide to EOC staff. ECT's are also instructed that if they do not understand what the medical condition is, assistance must be gained from the Clinical Support Desk Primary or rescue cardiac angioplasty (PCI) Vascular emergencies ruptured abdominal or thoracic aortic aneurysm Or aortic dissection transection Immediate cardiothoracic surgery for stab gunshot wound or emergency cardiac surgery Major trauma management (e.g: transfer of severely injured patient to regional major trauma centre) Paediatric sepsis when retrieval service is not available Neurosurgical transfer for evacuation of inter-cranial haematoma, management of sub- arachnoid haemorrhage or neurosurgical intensive care Transfer from midwifery Led Unit to Obstetric Delivery suite for fetal or neonatal distress anti-partum or post-partum haemorrhage or maternal or neonatal medical emergency Stroke Eligible for thrombolysis or mechanical thrombectomy (if not provided on site) To ensure that TCT requests are made by clinicians and are made in appropriate circumstances, as well as the mail drop described above, requests for inter-hospital TCT's will now be audited by SCAS and feedback will be provided to acute Trusts and commissioners when there is discrepancy between the information provided when the request was made and the clinical condition of the patient when SCAS arrive. This is because it is important to ensure that SCAS resources are used appropriately and are not diverted from medical emergencies in the community unnecessarily: This process will also identify at an early stage occasions where re- education or further engagement with acute Trusts is required 'Consider where the "Use of Standby Points policy needs to be refreshed to make it clearer and more consistent' In response to this point; the Trust has reviewed the said policy and amended section 7.13 which previously read:
7.13 Staff requests for facilities will be accommodated and honoured where reasonable; these will be at the most locally Trust recognised star facility in the area unless specific requirements for welfare create a need to return to another suitable location: for example change of uniform or health requirements. A request for facilities use and welfare is a shared staff and EOC responsibility: to confirm that it will not be considered reasonable to request the use of facilities where a crew has been dispatched to a Time Critical or Category _ call: understand that Miss Saunders has already informed you that making changes to this policy requires review by staff union representatives in addition to senior members of the operational team: The final review will take place on 13th February 2018 and we will of course forward a copy of the amended policy to you once it has been finalised. hope that this letter has addressed your concerns, but please do come back to me if you wish to discuss this matter further.

Report sections

Investigation and inquest

On 27 April 2015 the Senior Coroner, David Horlsey, commenced an investigation into the death of Rafe Robbie Angelo who survived 37 minutes after birth on 23" September 2014_ The investigation concluded at the end of the inquest on 7th November 2017 recorded the following NARRATIVE CONCLUSION: Rafe Robbie Angelo was born on the labour ward at the Queen Alexandra Hospital in Portsmouth at 17.30 hrs on 23rd September 2014. His mother, had gone to the Blake Birthing Centre at 04.30 hours the same in active Iabour. After artificial rupture of lamniotic membranes thinly stained meconium was noted and persisted until 14.15 when first stage of labour was complete. After an hour of oushing at 15.20 thick meconium was noted and a decision was made t0 transfer to hospital by ambulance. The ambulance arrived at hospital at 16.40. CTG monitoring began at 16.55 and was classified as pathological at 17:10 requiring a forceps delivery: Rafe was delivered by spontaneous vaginal delivery at 17:30, was pale and floppy, not breathing and tests showed he was severely acidotic. The grave nature of Rafe's condition was not recognised at the hospital until 20 minutes before delivery due to a number of delays between the appearance of thick meconium and eventual delivery as well as a series of communication failures between staff at the Blake Birthing Centre, the ambulance service and hospital staff including: Not requesting a time critical transfer by ambulance; The ambulance making a non-urgent stop after despatch; The full history and the need for urgent delivery including the change t0 high risk were not communicated. the day

As a result; Rafe died after 37 minutes of profound resuscitation at 18.07 the same decided the medical cause of death was: 1a) Acute global cerebral hypoxialischaemia; 1b) Umbical cord compression.

Circumstances of the death

was admitted to (he Blake Birthing Centre (the Blake) on 23 September 2014 at 4.30 am after 39 weeks pregnancy: She reported having contractions for two days and was found t0 be in active labour as she was 5 cms dilated. Fetal heart rate (FHR) was regularly monitored by intermittent auscultation using a handheld Doppler and found to be normal with no decelerations. A change of midwife occurred at 08.10 and as little progress in dilation had been achieved by 09.25, an artificial rupture of membranes took place. This caused some progress as shortly afterwards dilation was noted to be 7cm. By 09.25 thinly stained meconium was noted but no decision made to transfer t0 hospital. Throughout this period FHR continued to be checked regularly and was within normal variability and no decelerations heard. However; by 11:10 babys heart rate had dropped below baseline of 130-135 t0 110-115 beats per minute (bpm). The rate dropped again at 11.30 and the midwife consulted a colleague who suggested tdE Ito change position: This led to FHR baseline improving: At 12 noon; a discussion took place about pain relief and possible use of the birthing pool but this was not possible until 14.30. Thinly stained meconium was still noted at 14.15 by wheni was fully dilated and the first stage of labour had been completed: Contractions continued and by 14.55 was feeling the need to push At 15.10 a discussion takes place about transfer t0 hospital. The midwife recorded in her notes that this was the first time a transfer had been requested. land her family told me that by this time several transfer requests had been made. A second midwife came t0 examinel land when she was asked to out of the pool; thick meconium started t0 drain and a decision was made by the midwives t0 request an ambulance and transfer to hospital. Throughout this time regular checks were made 0n baby's heart with no concerns regarding decelerations_ A maternity support worker made the call to the ambulance service at 15.37 and an ambulance was dispatched at 15.46 arriving at the Blake at 16.08. In the meantime, a midwife at the Blake bleeped the relevant midwife at the hospital to report her findings in advance of mother's arrival at hospital. Further dark liquor was noticed and FHR continued to be checked with no apparent cause for concern; The ambulance left the Blake at 16.22 under blue lights and used the siren when needed to navigate through traffic arriving at hospital by 16.40. The midwife travelled with Ms Angelo and her sister and continued to check the FHR in ambulance. These timings were confirmed from SCAS computer records_ The midwife recorded that the party arrived at the labour at 16.52 and electronic fetal monitoring by CTG began at 16.55 and recorded baby's heart rate as 127 bpm, have noted that the midwife's timings were at slight variance with SCAS records. By 17.05 the FHR was 120 but contact was lost. When the CTG transducer was repositioned there were deep and repetitive decelerations which were recognised as pathological The Registrar who came on at 17.00 carried out a review at 17.10 and decided an instrumental delivery by forceps was appropriate to expedite delivery: day: get the 'ward duty

At stage there was loss of contact with FHR and a fetal scalp electrode was requested:. Following administration of a local anaesthetic an episiotomy was performed at 17.25 but spontaneous vaginal delivery was achieved at 17.30, was born through thick meconium and was pale and at birth with no spontaneous movements Or respiratory effort: Cord blood was obtained: The paediatric registrar checked baby's airway but could not see any obstruction by meconium: No heart rate was heard and cardiac compressions were started. Baby was intubated and adrenaline given: At 11 minutes of age no gasps were noted and no heart rate recorded but at 17 minutes and 25 seconds of Iife a slow heart rate was heard. Ata later stage after further cardiac compressions, the saturation monitor was picking up regular pulse and after palpation, weak femoral pulses were detected. At 23 minutes the heart rate was more than 100 beats per minute but by 29 minutes the heart rate was Iost on the monitor. Although the consultant thought she could hear a heart rate at 30 minutes by 33 minutes no further heart beat was heard. Resuscitation efforts stopped after 37 minutes at 18.07 and this was noted as time of death: A post mortem was carried out on 8 October 2014 and the pathologist concluded there was evidence of an acute hypoxic mode of death mostly likely caused by umbilical cord compression during delivery:

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: YouR RESPONSE You are under a to respond to this report within 56 of the date of this report, namely by 22 January 2018. !, the coroner, may extend the period: Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed_

Copies sent to

2. St George's University of London Portsmouth Hospilals NHS Trust Head of Maternity, Portsmouth Hospitals NHS Trust

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Report details

Reference: 2017-0421
Date of report: 27 November 2017
Coroner: Karen Harold
Coroner area: Portsmouth & South East Hampshire

Responses identified

Responses identified 2 of 3

1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 24 Apr 2018 (estimated).

Sent to

Department for Health

Portsmouth Hospitals NHS Trust

South Central Ambulance Service NHS Trust

Source links

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