Source · Prevention of Future Deaths

Jennifer Clark

Ref: 2017-0001 Date: 12 Jan 2017 Coroner: Thomas Osborne Area: Bedfordshire and Luton Responses identified: 1 / 1 View PDF

The neonatal unit has insufficient beds and is inadequate for the high number of births, despite an expansion proposal being rejected. This severe lack of facilities poses a high risk to babies' lives.

Date 12 Jan 2017
56-day deadline 16 Apr 2017 est.
Responses identified 1 of 1
Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
The neonatal unit has insufficient beds and is inadequate for the high number of births, despite an expansion proposal being rejected. This severe lack of facilities poses a high risk to babies' lives.
View full coroner's concerns
In the circumstances it is my statutory to report to you: _ Consultant Paediatrician from the Hospital, the course of his evidence, explained that there were over 5,500 births at Watford General Hospital every year, and that the Neonatal Unit only had a limited number of beds and was inadequate for that number of births. Despite having submitted a detailed Proposal for Expansion of the Neonatal Unit, this had been rejected Without adequate neonatal facilities at the Hospital there is a high risk of babies' lives at risk in the future

Responses

1 respondent
West Hertfordshire Hospitals NHS Trust NHS / Health Body
8 Mar 2017 PDF
Action Planned

The Trust states that it has adequate neonatal facilities but acknowledges that the Neonatal Unit requires modernisation. The Trust Board approved a redevelopment plan including the NICU and the Strategic Outline Case is awaiting consideration. (AI summary)

View full response
Dear Sir am to you to respond to the concerns raised by Mr Thomas Osborne's investigation into the circumstances surrounding the tragic death of Jennifer Clark, which led to him making regulation 28 report with respect to the issues discussed at the conclusion of the Inquest on 10 January 2017. Mr Osborne was concerned that without adequate neonatal facilities at Watford General Hospital there is high risk of babies' lives at risk in the future. Based on the latest figures available, in 2015 5451 babies were delivered at Watford General Hospital. The Neonatal Intensive Care Unit (NICU) is designated Level 2 unit which provides neonatal care for the population within the West Hertfordshire catchment area, except for the sickest babies who require complex or longer-term intensive care in Level 3 unit_ We have a total of 24 cots (3 intensive care cots; 5 high dependency cots and 16 special care Babies requiring Level 3 intensive care are transferred to the nearest Level 3 Intensive Care Unit within our regional neonatal network Within the East of England Neonatal Operational Network there are eight units. Department of Health Toolkit for High Quality Neonatal Services suggest that planned capacity should not exceed an average occupancy of 80%. Our aggregate occupancy rate for all cots in 2015 was 69%. The Trust has, since 2015, Neonatal Unit Admissions and Escalation Policy (enclosed): which sets out what actions are required when the Unit reaches 90% capacity_ http:Ilwww londonneonatalnetwork org uklwp-contentluploads/2015/09/Toolkit-2009 pdf Charr: Professor Steve Barnett Chief Executive Katie Fisher westhems iOspials nhsu.k #ar 0 MCE AOlL writing being cots) .

Reflecting on the available data and Department of Health guidance set out within the Toolkit, the Trust considers that for the number of births there is adequate facilities available at Watford General Hospital. We do however recognise that the Neonatal Unit, along with many of our buildings, requires modernisation: On 2 February 2017 the Trust Board approved redevelopment plan as part of the Your Care Your Future Programme; which will include extensive redevelopment of hospital estates and facilities and this will include plans for development of the NICU. The Trust's Strategic Outline Case is due to be considered at the Herts Valley Clinical Commissioning Group Board meeting; at the time of writing a date is to be set. hope that the information provided offers assurances that the area highlighted in the prevention of future deaths report is being adequately managed and that there are wider plans that are going to improve services across the whole site for patients who require variety of the services we are able to offer: We will continue to work with Level 3 Neonatal Intensive Care Units in ensuring the safety of babies born at Watford General Hospital who may require intensive care_

Report sections

Investigation and inquest
On 6 October 2014 commenced an investigation into the death of Jennifer Elisabeth Lestajo
Circumstances of the death
Jennifer was born on the 24 September 2014 after a birthing = deiivery_ The midwife failed to recognise that baby Jennifer wes unweil until the time of her coliapse, some minutes after delivery. She was then transterred to the Luton & Dunstable hospits] for firther treatment where she died, Senior Corener; The Court House_ Woburn Street

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Report details

Reference
2017-0001
Date of report
12 January 2017
Coroner
Thomas Osborne
Coroner area
Bedfordshire and Luton

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: 16 Apr 2017 (estimated).

Sent to

West Hertfordshire Teaching Hospitals NHS Trust

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