Source · Prevention of Future Deaths

Mohammed Yousaf

Ref: 2015-0056 Date: 16 Feb 2015 Coroner: Lisa Hashmi Area: Manchester (North) Responses identified: 0 / 3 View PDF

There are no national guidelines on how to interpret and/or classify antenatal CTG tracings, and there were concerns about the dissemination, application, and applicability of the Trust’s Interpreting Policy, specifically regarding obtaining informed consent.

Date 16 Feb 2015
56-day deadline 13 Apr 2015 est.
Responses identified 0 of 3
Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
There are no national guidelines on how to interpret and/or classify antenatal CTG tracings, and there were concerns about the dissemination, application, and applicability of the Trust’s Interpreting Policy, specifically regarding obtaining informed consent.
View full coroner's concerns
During the course of the inquest the following concerns were identified:
1. Whilst Pennine Acute Hospitals NHS Trust has now established its own local guidelines based upon recent research conducted in Bristol, there are no national guidelines on how to interpret and/or classify antenatal (as opposed to intra-partum) CTG tracings.
2. The dissemination, application and applicability of the Trust’s Interpreting Policy, by its staff, in force at the material time (with particular regard to the obtaining of informed consent).

Report sections

Investigation and inquest
On the 11 th February 2015 I commenced an investigation into the death of infant Rahat Qayyum (otherwise known as Mohammed Rahat Yousaf).
Circumstances of the death
On the 5” July 2013, the deceased’s mother was admitted for planned induction of post-term labour. At around 15:50 hours, a CTG demonstrated anomalies. The midwife sought a medical review. The initial CTG demonstrated recovery however by 20:50 hours, a further trace showed evidence of a more marked anomaly. The significance of this CTG was not fully recognised. At 22:00 hours doctors made the decision to proceed to emergency caesarean section. As a consequence, the deceased’s mother was transferred to the labour ward at around 22:20. At 22:48 a further examination was carried out by a doctor during the course of which an artificial rupture of membranes was performed. Tenacious, fresh meconium was noted within the liquor. The deceased’s mother was transferred to theatre at 22:53 with baby being delivered in a very poor condition at around 23:42. Neonatal resuscitation was commenced immediately and thereafter, the deceased was transferred to the NICU. Over the course of the next few days, tests showed that the deceased was suffering from electrocerebral silence, meconium aspiration syndrome, seizures, hypoxic cardiomyopathy and presumed sepsis. The deceased’s condition continued to deteriorate and he died on the 19 th July 2013 from hypoxic ischaemic encephalopathy due to or as a consequence of perinatal asphyxia.

During the course of the treatment and care provided, an official Interpreter was not summoned or utilised.

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Report details

Reference
2015-0056
Date of report
16 February 2015
Coroner
Lisa Hashmi
Coroner area
Manchester (North)

Responses identified

Responses identified 0 of 3
3 responses not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 13 Apr 2015 (estimated).

Sent to

Department of Health and Social Care
Pennine Acute Hospitals NHS Trust
Royal College of Obstetricians and Gynaecologists

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