Source · Prevention of Future Deaths

Antonio Allen

Ref: 2014-0351 Date: 31 Jul 2014 Coroner: John Pollard Area: Manchester (South) Responses identified: 1 / 1 View PDF

Midwives were repeatedly uncontactable for an overdue home birth, leading to the delivery being performed by family members before their eventual arrival.

Date 31 Jul 2014
56-day deadline 25 Sep 2014 est.
Responses identified 1 of 1
Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
Midwives were repeatedly uncontactable for an overdue home birth, leading to the delivery being performed by family members before their eventual arrival.
View full coroner's concerns
It had been arranged that this was to be a home birth and the midwives based at Lostock Medical Centre were aware of this_ His expected date of delivery was the 15th June but in fact he was born on the 17th June. The mother and grandmother of Antonio tried on four separate occasions to call out a midwife to attend the birth but in fact the delivery had to be carried out by the grandmother and a neighbour: Two midwives eventually arrived, checked the baby and said all was well although he was a bit 'puffy' because it was a 'quick birth' IF A HOME BIRTH IS BOOKED AND EXPECTED OR INDEED OVERDUE, IT SHOULD NOT BE THE CASE THAT THE MIDWIVES ARE NOT CONTACTABLE, NOR THAT THEY ARRIVE AFTER THE BIRTH HAS OCCURRED:

Responses

1 respondent
Central Manchester University Hospitals NHS NHS / Health Body
24 Sep 2014 PDF
Action Taken

Following a telephone line failure, women are now given two telephone numbers to call for planned home births. A standard operating procedure is in place to check essential telephone lines are fully functioning. (AI summary)

View full response
Dear Mr Pollard Re: Antonio Jerome ALLEN (Deceased) Thank you for your letter to Sir Michael Deegan of 31st 2014, he asked me to on his behalf: instructed the clinical team to review the case and haveasea oectheearsveery to the points noted in the Regulation 28 notification below. The priority of the maternity directorate is to provide safe and high quality maternity care for allwomen and their partners regardless of their choice of place of birth: Options for place of birth are discussed with the woman and her partnerlfamily to enable women to make an informed choice At the booking consultation a full medical, surgical, obstetric and social is taken to support women in their decision by discussing the risks and benefits of choices available: Women are also given an information leaflet to enable them to discuss their options further with their family: Maternity staffing is managed to ensure that the community midwifery team can respond to requests from women at any time of the day or night when a home birth is planned in order to ensure women and their family receive optimal care and support. On the 17th June 2013 at approximately 04.20 hours community midwifel was informed by fellow midwife, working on the midwifery led unit; of the imminent delivery at home address_ Midwifel Jimmediately collectedtthe emergency equipment and attended Patient A's home_ On arrival at 04.44 hours was on the kitchen floor with her baby placed on her abdomen (skin to skin). Midwife performed a full risk assessment once and her baby Were comfortable and settled and made the decision that it was safe for both to remain at home. The mother of informed Midwife Jthat she had telephoned the dedicated telephone number approximately 04.00 on four occasions until approximately (04.20
04.30 hours) but her call was not answered: (All women who are booked for a planned home birth are given a dedicated number to contact, This telephone line is normally in operation 24 hourslday). mother reported that she then called the department who transferred her calrto the community midwifery team: INVESTORS Manchester Royal Eye Hospital Manchester Rcporanfmnary Royal Manchester Children'$ IN PEOPLE Saint Mary'$ Hospital Trafford Hospitals University Dental Hospitasoe Mancheste Hospital Community Services Di5aBLt9 July has fully history from Triage #our 6 1

Central Manchester University Hospitals NHS] NHS Foundation Trust Following her return to the hospital Midwife lalerted the radio telephone administration staff of the difficulties experienced by the family: On investigation it was identified that there had been a known fault on the telephone line earlier in the day but this had been resolved by the engineers_ There is a process in place to ensure that the essential telephone lines are checked at the beginning of each shift; it was apparent that the administrator did not follow the process for checking the phone line at commencement of their shift so was unaware that the fault had reoccurred. On informed by Midwife lof the unanswered phone calls the administrator notified switchboard of the fault on the line and immediate action was taken to reconnect the telephone line_ To ensure that this never happens again women are now given two telephone numbers to call in case one line is busy or faulty standard in piace to check that the essential telephone liney areafuily functioning operating procedure

Report sections

Investigation and inquest
On 22nd July 2013 commenced an investigation into the death of Antonio Jerome Allen dob 17t June 2013. The investigation concluded on the 18"h June 2014 and the conclusion was one of Natural Causes. The medical cause of death was Ia Intra-abdominal Haemorrhage 1b Sub-capsular Haematoma (Liver and Spleen)
Circumstances of the death
On the June 2013 at 07.40 hours, Antonio Allen was admitted to Trafford General Hospital in cardiac arrest with no respiratory effort and no palpable pulse_ His mother had breast fed him at 01.00 hours and then found him unresponsive at 06.45 hours. Despite the best efforts of the ambulance and Emergency Department personnel;_he could not be_ revived
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you have the 26th _

power to take such action_

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Report details

Reference
2014-0351
Date of report
31 July 2014
Coroner
John Pollard
Coroner area
Manchester (South)

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: 25 Sep 2014 (estimated).

Sent to

Central Manchester NHS Foundation Trust

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