Source · Prevention of Future Deaths

Nathan Healer

Ref: 2014-0343 Date: 25 Jul 2014 Coroner: Derek Winter Area: Sunderland 1 response identified · 1 indexed addressee View PDF

AI-generated concerns summaryThe coroner raised concerns regarding the delay in finalising new NICE guidance on diabetes in pregnancy, specifically whether it can be expedited. There was also a recommendation to revisit existing guidance if new recommendations are not forthcoming.

Date 25 Jul 2014
56-day deadline 22 Sep 2014 stated in the report
Responses identified 1 of 1
Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
The coroner raised concerns regarding the delay in finalising new NICE guidance on diabetes in pregnancy, specifically whether it can be expedited. There was also a recommendation to revisit existing guidance if new recommendations are not forthcoming.
View full coroner's concerns
_ was made aware of: City a) the 2008 NICE Clinical Guidance 63 "Diabetes in Pregnancy" which in essence recommended a pre 2nd Feed Blood Glucose test at between 2-4 hours; b) the hospital Guidance for "Hypothermia in the newborn Infant" 2014; c) the hospital Guidance for "Prevention , detection and management of hypoglycaemia in the newborn 2012 (Blood glucose test at around 4 hours). Although the severity of Nathans's condition was not appreciated and he was not given the opportunity of a more timely blood glucose test heard evidence that although new guidance from NICE is in contemplation it has not yet been finalised_ If that is the case then it would be helpful to know what stage this is at and whether any steps can be taken to expedite it's production. If no new guidance is in contemplation then it may be an opportune moment to revisit the guidance in any event;

Responses

1 respondent

Department of Health

Central Government
Indexed date: 3 Sep 2014 PDF
AI-classified response stance Noted
AI-generated response summary

• The Department of Health stated that draft guidance for NICE Guideline CG63 was scheduled for consultation in September 2014. • The Department of Health indicated that the finalised guidance was anticipated for publication in February 2015. • The Department of Health noted that expediting the guidance finalisation process was not possible.

View full response
From Dr Dan Poulter MP Parliamentary Under Secretary of State for Health Department Richmond House of Health 79 Whitehall London POCS 887782 SWIA 2NS Teli Mr D Winter Senior Coroner Civic Centre 0 3 SEP 2014 Bourdon Road Sunderland SR2 ZDN 0 8 SEF O_ A Thank you for your letter following the inquest into the death of Nathan Healer. In your report You conclude that the medical cause of death was Neonatal Encephalopathy and Intraventricular Haemorrhage (Grade 4), and Poorly Controlled Gestational Diabetes. Nathan'$ mother had gestational diabetes, and kept regular contact with medical professionals throughout her pregnancy: You noted that Nathan was born on 3rd February 2014 at 7.18am without complications, and his APGAR test results were However; his colour was not all that it ought to have been, and he was cold and slow to feed. It was also reported that his eyes were bulgy, he had jittering arms and excessive startle reflux. You further noted that Nathan's blood glucose was measured for the first time at almost five hours from his birth, registering at 0.2mmol/L. Although intervention began at this point; Nathan died two later on 5th February 2014. You raise the following matters of concern: The 2008 National Institute for Health and Clinical Excellence (NICE) Guideline CG63 'Diabetes in Pregnancy in essence recommended a pre 2"d feed blood glucose test at between 2-4 hours. Although the severity of Nathan '$ condition was not appreciated, and he was not given the opportunity of a more timely blood glucose test, you understand that new guidance from NICE is in contemplation but has not yet been 2014 ~x, good. days

finalised, and would like to know what stage this is at and whether it can be expedited We understand that NICE Guideline CG63 is currently under review: Draft guidance is due to go out for consultation on 11th September 2014, ending October 2014. The finalised guidance is expected to be published in February 2015. Further details about this work can be accessed on the NICE website at the following address: http:Lwww nice org uklguidancelindevelopmentIGDD-CGWaveRL0Z Given the imminence of the new guidance, advice from Departmental policy officials is that there is no scope for this process to be expedited. However; as NICE is an independent body, advise you contact it directly with any further questions You may have about the review of this guidance. I hope that this response is helpful and am grateful to you for bringing the circumstances 0f Nathan'$ death to my attention_ Sa8 DR DAN POULTER 23rd 6

Report sections

Investigation and inquest
On 06/02/2014 commenced an investigation into the death of Nathan James Healer , at 2 days of age. Following his death on 05/02/2014, the investigation concluded at the end of the inquest on 24/07/2014_ The conclusion of the Inquest was "Although the severity of Nathan's condition was not appreciated and he was not given the opportunity of a more timely blood glucose test he died of a natural cause" Medical cause of death was confirmed as: Ia Neonatal Encephalopathy and Intraventricular Haemorrhage (Grade 4); 2 Poorly Controlled Gestational Diabetes
Circumstances of the death
Nathan's mother had gestational diabetes and during the pregnancy had very regular contact with medical professionals _ Nathan was born on 03/02/2014 at 0718 hours without complications and his Apgar scores were good. However his colour was not all that it ought to have been; he was cold and was slow to feed. It was also reported that his eyes were bulgy, he had jittering arms and excessive startle reflux: When his Blood Glucose was measured for the first time at almost 5 hours from his birth it was 0.2 mmol/L. Despile intervention at this point Nathan died on 05/02/2014_
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action_

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Report details

Reference
2014-0343
Date of report
25 July 2014
Coroner
Derek Winter
Coroner area
Sunderland

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: 22 Sep 2014 (stated in the report).

Sent to

Department of Health and Social Care

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