Dominic Smith
30 Jun 2016 · Coroner Lisa Hashmi · Manchester (North)
This report repeats 2 earlier warnings. See the linked reports.
The coroner's concerns
1. lack of antenatal screening for group B streptococcus
“That antenatal screening for GBS was not being routinely offered by the NHS to all pregnant - women during the final weeks of pregnancy”
2. inadequate communication handover and record keeping
“Staff did not follow the Trust's protocols/guidance and did not document their rationale where - they exercised clinical discretion”
3. failure to assess rupture of membranes
“Midwives did not carry out a speculum examination, on two separate occasions, in order to - establish whether there had been a rupture of membranes”
4. lack of neonatal observations
“Neonatal observations were not carried out when it became apparent that there had been a - material change in baby's condition”
5. inadequate maternal monitoring
“Maternal observations were not carried out after delivery, despite a spike in temperature”
6. failure to seek specialist consultation
“Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist”
Linked reports
Identical hazardConfidence 0.95 · high
Earlier report
“That antenatal screening for GBS is not routinely offered by the NHS, to all pregnant women, during the final weeks of pregnancy.”
This report
“That antenatal screening for GBS was not being routinely offered by the NHS to all pregnant - women during the final weeks of pregnancy”
Closely relatedConfidence 0.90 · high
Earlier report
“During the course of the inquest hearing it became apparent that the nursing tools (in particular, the 'Purpose T'), assessments, records, associated documentation and nursing discharge summary were incomplete and/or inaccurate.”
This report
“Staff did not follow the Trust's protocols/guidance and did not document their rationale where - they exercised clinical discretion”
Responses
2016-0240-Response-by-RCPCH.pdf ↗· Department of Health and Social Care
Stated action
“the RCPCH is unable to comment on the specifics of the case and the Pennine Acute Hospitals NHS Trust has been asked to respond directly on local communication, record keeping and policies and procedures.”
2016-0240-Response-by-The-Pennine-Acute-Hospital-NHS-Trust.pdf ↗· Pennine Acute Hospitals NHS Trust
Stated action
“The Division of Women and Children's is undertaking a programme of rolling audits on communication and documentation. The purpose is to ensure compliance with policy standards and to identify areas where there are challenges in order to implement remediating measures.”
Stated action
“The division has commissioned an improvement programme of work focusing on these three areas in order to fully embed effective and reliable processes into clinical practice.”
Stated action
“There has been guidance issued to all practitioners to reiterate the need to obtain a thorough, probing history from the patients to ensure questioning covers the potential rupture of membranes in line with policy and carry out an appropriate speculum examination.”
Stated action
“Undertaking correct acute monitoring of patients condition, through using early warning scores is currently a Trust wide project to improve practice.”
Stated action
“The neonatal services has developed a module of training entitled Care of the Compromised Infant, which now forms part of each midwife's mandatory training; the .....”
Stated action
“The Division have developed a programme of training to emphasise recognition of signs and symptoms or deviations from normal physiological observations.”