Source · Prevention of Future Deaths

Isla Lord

Ref: 2016-0035 Date: 5 Feb 2016 Coroner: Thomas Osborne Area: Bedfordshire and Luton Responses identified: 1 / 1 View PDF

A critical lack of liaison between tertiary and local hospitals resulted in no agreed delivery plan for a baby with identified heart anomalies, increasing risks for mother and child.

Date 5 Feb 2016

56-day deadline 2 Apr 2016

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

A critical lack of liaison between tertiary and local hospitals resulted in no agreed delivery plan for a baby with identified heart anomalies, increasing risks for mother and child.

View full coroner's concerns

1. During the course of the evidence it became apparent that once the possibility of heart anomalies was identified at University College Hospital in London (UCLH), there was no liaison between Princess Alexandra Hospital in Harlow and UCLH as to the plan for the delivery of the baby. It was simply agreed that UCLH were content for her to be delivered at the local hospital with a referral being made to Great Ormond Street Hospital after delivery. In order to prevent deaths in the future there needs to be a review of the system that exists between the tertiary hospitals and Princess Alexandra Hospital as to how to formulate an Agreed Delivery Plan for both mother and baby.

Responses

1 respondent

I lord

8 Mar 2016 PDF

Action Taken

The Standard Operating Policy for obstetric ultrasound scanning has been amended to include consultant requests for detailed delivery plans from tertiary centers, documented in patient notes. This policy has been added to the Trust guidelines, obstetric doctors have been notified, and referrals to tertiary centers will be monitored by the weekly Multidisciplinary Paediatric Plans of Care Meeting. (AI summary)

View full response

Dear Mr Osborne RE: REGULATION 28 REPORT TO PREVENT FUTURE DEATHS write further to your report following the Investigation into the death of Isla Peyton Lord which requested a review of the system that exists between the tertiary centres and the Princess Alexandra Hospital on how to formulate an Agreed Delivery Plan for both mother and baby. would like to assure you of the following: The Standard Operating Policy for obstetric ultrasound scanning has been amended to include that consultants in charge of patients referred for second opinion in tertiary centres should request detailed plan for delivery of the mother and care of the baby The policy also requests the consultants to document the plan clearly in the patient's hand held notes and hospital notes_ 2 The new policy has been added to the Trust guidelines folder accessible by all clinicians 3_ Obstetric doctors have been notified of the policy: Referrals to tertiary centres will be notified to and monitored by the weekly Multidisciplinary Paediatric Plans of Care Meeting: am confident that the above actions will ensure the prevention of avoidable neonatal deaths_ Kind regards_

Report sections

Investigation and inquest

On 19 November 2012 I commenced an Investigation into the death of Isla Peyton LORD, aged 4 days . The Investigation concluded at the end of the inquest on 28 January 2016. The Conclusion of the Inquest was a ‘Narrative Conclusion’ that “… Isla Peyton LORD was born on 4 November 2012 at the Princess Alexandra Hospital in Harlow. Following delivery she suffered an inexplicable immediate post-natal collapse; initial attempts at resuscitation were unsuccessful and she suffered a hypoxic ischaemic brain injury. She was transferred to the Luton and Dunstable Hospital where she died on 8 November 2012.

Circumstances of the death

Isla was born at Harlow Hospital on the 4th November 2012. During pregnancy, an antenatal scan detected the right leg bent above the knee. There were also concerns over an enlarged heart chamber. She was born by Emergency C Section; she cried upon delivery, however, then collapsed. There was a prolonged period of resuscitation and she was found to have a hypoxic brain injury. She was subsequently transferred to the Luton

Tel 0300-300-6559 | Fax 0300-300-8267

and Dunstable Hospital at 06.00 hours on the 5th November 2012, where she was ventilated. Discussions then took place with Isla's parents when a decision was made to withdraw treatment. She sadly died on the 8th November 2012.

Copies sent to

Tel 03006559 | Fax 03008267Hertfordshire Safeguarding Children Board Team, Room 147, Postal Point CHO143, County Hall, Hertford. SG13 8DF admin.hscb@hertfordshire.gov.uk

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Shared signals

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Report details

Reference: 2016-0035
Date of report: 5 February 2016
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: 2 Apr 2016.

Sent to

Princess Alexandra Hospital NHS Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.