Source · Prevention of Future Deaths

Jared William McDowall

Ref: 2013-0245 Date: 27 Sep 2013 Coroner: Maria Voisin Area: Avon Responses identified: 1 / 1 View PDF

Inadequate guidelines for identifying at-risk babies, including a lack of specific weight-for-gestation criteria and poor data presentation. Joint training for doctors and midwives on hypoglycaemia is also needed.

Date 27 Sep 2013

56-day deadline 22 Nov 2013 est.

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

View full coroner's concerns

During the inquest heard evidence of a cut off weight for babies to go into a transitional area where they will receive more careful monitorina Currentlv the guideline is babies weighing over 2_ do not need to go into this unit: Consultant Neonatologist from the hospital gave evidence about this and indicated that there should be different weights for gestation and different guides for boys and girls: He also said that the presentation of the evidence would be better if it was graphically done and that by referring to a graph it would give a better understanding of a baby being at risk to the staff In addition said that there was a need to synthesize joint working with doctors and midwives_ That there should be educational packages for hypoglycaemia and for recognising an unwell baby for both doctors and midwives with a measurement of competency

Responses

1 respondent

University Hospital Bristol Education

25 Oct 2013 PDF

Action Planned

University Hospitals Bristol has created a composite action plan to address concerns raised in two Regulation 28 reports and will monitor the plan's implementation through the Trust's governance procedures. (AI summary)

View full response

Dear Mrs Voisin Regulation 28 Report Ref 00231/20012 and Ref 03754/2012 Further to the recent inquests, into the deaths of Jared McDowall and Rose Coles, please find attached a composite action plan addressing the matters of concern addressed within the two Regulation 28 Reports issued to the Trust on the Ist October 2013. The Trust is confident that the actions described, many of which are already in hand, will address the concerns expressed and mitigate the risk identified of future deaths attributable to these factors_ The action plan will be monitored through the Trust's governance procedures to ensure its full implementation. Please do not hesitate to contact me if you require any further information_

Report sections

Investigation and inquest

On 24th January 2012 commenced an investigation into the death of Jared William MCDOWALL, aged 48 hours The investigation concluded at the end of the inquest on 26th September 2013. conclusion of the inquest was Ia Unexpected death of a neonate with raised insulin level, anisonucleosus in islets, focal pulmonary haemorrhage with low birth weight

Circumstances of the death

Jared was born on 15lh January 2012 at St: Michaels Hospital and died there unexpectedly at 02.45 hours on January 2012,

Action should be taken

In my opinion action should be taken to prevent future deaths and believe your organisation has the_power _to _take such action. The 17ln 5kg

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Shared signals

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Report details

Reference: 2013-0245
Date of report: 27 September 2013
Coroner: Maria Voisin
Coroner area: Avon

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 Nov 2013 (estimated).

Sent to

University Hospitals Bristol NHS Foundation Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.