Tommi-Ray Vigrass

Dear Mr Siddique Re: Tommi-Ray Vigrass (Deceased) Date of Birth: 09/01/2016 Date of Death: 13/01/2016 Date of Inquest: 23/06/2016 in response to your report under paragraph 7 Schedule 5,%f the Coroners and Justice Act 2009 adgegutatioonse3tanoug eorhencoroners_(investigations) Reguiations 2013. fully accept the Inquestverdict that Tommi-Ray Vigrass"s death was contribuled to by neglect would like to take the opportunily to assure you_that a formal policy for reporting and investigating incidents is embedded within Ihe Trust Tommi-Rays case has been subject to this process: serious this case seriously and the Root Cause Analysis has been reviewed following the We have laken that identified actions are being taken and compleled in a timely manner The learning Inquest to ensure and the internal investigation wll be shared with staff across the organisation: from both the Inquest Circumstances of Tommi-Ray' $ death Baby Tommi-Ray was bom on Ihe 9 January 2016 at 28+2 weeks gestation and/weighed 1.02kg He had developed Respiratory Distress Syndrome and required ventilator support The Doctor responsible for his care described that the ventilator was showing persistent leak "shroughout ihe evening of the 9 January into the morning 0f the 10 January: and kept alarming Tommi-Ray and change the endotracheal tube (ET) to size 3 at 320am He decided to extubate Tommi-Ray was tried on BIPAP initially but his on the 10 January: The original tube was 2.Smm; oxygen saturations began (0 drop and he required manual ventilation After the initial attempt at intubation with a size 3 ET tube, Tommi-Ray became bradvcardichwile low oxygen saturations and the tube removed; Cardiac compression was commenced There he was intubaled There was good chest movement but his response was nO response was pOOr _ The ET tube was removed again. The on call Consultant was crash bleeped at 4am on 10 January and within 20 minutes he arrived the Neonatal Unit. He described that the ET tube was in situ but Tommi-F was promptly on He checked the ET tube with a CO2 detector but It did not turn vellow; The tube pale in colour commeonced He confirms that the after intubalion (he tube became was removed and bagging dislodged and further intubation was required. A size 3 ET tube was used Our ` and again again and Ray

Tommi was edentually stabilised and blood gas showed a PH of 6.68 which is very acidotic: Tommi-Ray was administered adrenaline and chest compressions continuedr The-Consultant confirmed that for premature babies weighing less than 1Kg in weight it was usual practice lo use a 2.5mm ET lube and in theatre Tommi-Ray was not initially weighed. was {0 insert the ube and slabilise him with furcernadiastmentsoadealr Iheigheonataeuiority cbeidCbasisky using a tube that-was (O0 big Which could tead €0 complicationse incedding stenosist The Consultant also confirmed he wasn" consulted about Ihe premature care plan,bg wenoold/ by a codeague that a molher had been admitled to the ward wilth & prematureebaby (however is not documented) this tertiary specialist Hospilal (New Cross Haspital-Level 3 Uni) was contacted but there were inchboacdltiestrm contacting ehe Neonatal Consultant despite multiple atfempts throughwere switchboard. A transfer to this tertiary Hospital was eventually accepted. Uhe Neonatal Consultant at New Cross Hospital described that when Tommi-Ray arrived on his Unitihe took over his care On the 12 January and came to the conclusion that heahadesuofered_ Rigniricant brain damage due t9 the hypoxic episode following his cardiac arrest: Sadly, Somnc died Ihe following day on 13 January 2016 Coroner' $ Concems During the course of the inquest the evidence revealed matlers giving rise to concern and a risk that future deaths will occur unless action is taken; MATTERS OF CONCERN were identified as follows: Evidence emerged during the inquest that the Paediatric Doctor In charge recognised that it was mistake to extubate Tommi-Ray when he did. His words were: "What should have been forward ET change turned into a nightmare" He also confirmed that he should have straight tha Consuliant on call prior (0 making the decision and eaferruee of ahe COhoulonitavwcordshaed made a difference. In addition, it emerged that there were problems and delays in trying to contact (he tertiary unit via the switchboard, There was also evidence 9f_an inadequate handover &nd preparation for the arrival of the premature with insufficient care plan details or consultation (aking place. Preventing Future Deaths Action for Walsall Healthcare NHS Trust SortiowasIncidenl investigation was carried out following Tommi-Rays death and & Root Cause Analysis report was fommulated with specific action plan Actions including the development of Standard Operating Procedure related to the difficult ainway kit had beenocompletecevaphandover: paadsed formalised: Fotur Ceanecrfcoutstanding actions were identified at the conclusion of the Inquest and a Preventing Future Deaths report has been issued lo the Trust: Alhough some Improvements have been made by the Trust through the of the Root Cause Analysis (RCA) Investigation, you may consider that expediting some of the action points in the RCA including training in the use %f the COZ indicatoome made hovepbesoridendffurther training for neonatal staff where deficiencies or gap roknowledge have been identified, Action Taken Neonatal staff have now 'undergone training on 'Difficult Airway Managemenl' This includes the use of Ray - The Ray The baby findings

Oropharyngeal airways Nasopharyngeal airways Laryngeal mask airway (LMA) CO2 detector Introducer Robert Shaw blade Video laryngoscope Bougie You may also wish to consider expediting the process to establish system to contact tertiary unlts wlthin area to minimise any delays In contacting the relevant staff for advice. Action Taken The Regional Cot Locator service is now in place out of hours. This has negated the requirement for staff to search for level 3 cots: You may also wish to consider a review to ensure systems and procedures are in place to ensure that all relevant detailslcare plan are avallable for the Consultant in charge when a mother delivers a pre-term baby in an emergency Action Taken All medical staff, Advanced Neonatal Practilioners and band 6 nursing staff now have access to (he Maternal Badgernet System in addition to Neonatal system This gives access t0 all relevant staff to view electronic records pertaining t0 antenatal care, inbapartum and postnatal: More generally we have introduced within the Trust around the development of a more safety focused culture which will encourage staff to be more aware of the potential for harm, risk management and the need to escalate concerns .This work is particularly focused on A&E, Maternity and Neonates and Paediatrics initially: In addition a Maternity and Neonatal Task Force has been established to oversee the improvements made, reporting into the Quality & Safety Commitlee of the Trust Board We fully acknowledge the serious nature of the failings the management of a baby'8 airway and its potential to result in a fatality. The lessons learned from Tommi-Rays case are to be shared with Neonatal staff through a bullletin, a team meeting and at the Paediatric Grand Round Finally; on behalf of the Trust; would like t0 take the opportunity t0 offer our unreserved apologles for the delay in diagnosis and treatment to Tommi-Rays family, along with our sincere condolences for their lss trust that the action already taken by the Trust along with the additional action set out In this letter will provide you with assurance that we have responded with the seriousness needed t0 improve the care we provide. Yows sinterely Vzzkuz Richard Kirby Chlef Executive your work during