Charlie Jermyn

22nd May May day his (5"h May the May May, have

During the course of Ihe inquest Ihe evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless aclion is taken: In the circumstances it is my statutory duly to report to you. At the inquest (he Head of Midwifery at the Royal Cornwall Hospital outlined significant changes that had been introduced to the Trust as a result of learning from (his death These included the implementation of the NEWS chart in the post-natal documentation and there was reassurance that immediate steps had been inroducedto reduce risk of future dealhs. In addition the Director of Nursing accepted Expert Midwife Consultant offer to share best practice documentation wilh Trust The inquest identified areas where work should be undertaken _ The Delay of over 5 hours, in full assessment of labour progress in Ihe Day Assessment Unit at Royal Cornwall Hospital on (he 8/g"h May 2015 was unacceptable(systemic failing). Routine physiological observations of mother and baby were not undertaken and recorded by (he Communily Midwives This practice is not in line wilh national practice. The accurate temperature, heart rate and other appropriate observations/ recording should be routine ad formally recorded with stethoscope and thermomeler etc (not just visual and touch) NEWS should be completed on all babies, The Royal Cornwall Hospital Trust core midwifery paperwork does not meet best practice or NICE guidelines and does not prompt midwives to undertake rouline physiological assessments_ AIl Community Midwives should be provided with standard equipment to include, ear thermometers, stethoscopes, blood sugar testing and SATS monitors and these should be used as routine practice to make routine observations on mother and baby: There was a recommendation by the Midwife Consultant that centile charts for each baby should be available in all hand held maternity records to assist midwives identify babies who are potentially at risk The Expert Midwife advised that the use of a single birth weight in the Trusts hypoglycaemic guidance (at risk at 2.5 kg) was not best praclice and suggested the use of three weights: pre tern, term, and late weight The telephone Maternity Helpline was inappropriately triaged by unregistered inappropriately trained and qualified slaff, who were unable to idenlify obvious and significant sepsis markers indicating the seriousness of the deterioration in Charlie's health No structured note taking or recording of Ihe call was made for future referral: Nor was the call tapedlrecorded. Helpline triage is a complex task and should only be undertaken after specialist training by an appropriately qualified person and the outcome of the conversations should be recorded formally in line wilh best praclice. The red signs for sepsis (in this case sleepy, possible respiratory distress (grunting) and difficulty in feeding) were overlooked resulting in a fatal delay in referral t0 specialist hospital supporttreatment Identifica of sepsis in new born babies is difficult and the staff and Trust should have had in place a systemic, rigorous and regular training in this area. The Trust's own clinical guidelines for the Prevention, Diagnosis and Treatment of Early Onset Neonatal Bacterial Infection,were not known to the midwives at the inquest The Expert flag ation

Midwife gave the opinion (hat the RCHT Trust guidelines were not consistent with (he NICE guidance or best practice on this matter (page 142) In particular it was noted that capillary re-fill time should be undertaken and recorded in cases of suspected sepsis. The Expert Midwife noted that RCHT Sl and SOM were not appropriate and been identified in the most recent LSA report on the Trust: