Prevention of Future Death report: Bethan Harris (22 June 2020)

Summary

On the 20 February 2019 an investigation commenced into the death of Bethan Naomi Harris who was born on the 16 November 2018 at the St George's University Hospitals NHS Foundation Trust.

Bethan Naomi Harris died at Shooting Star Hospice on the 26 November 2018. Her mother's pregnancy had been uneventful. After admission to labour ward labour progressed very quickly indeed and Bethan sustained severe brain injury during delivery. Despite best efforts by the neonatal team she succumbed to her injuries. The Investigation concluded at the end of the Inquest on the 19 November 2019. The conclusion of the inquest was that the medical cause of Bethan's death was (1a) hypoxic ischaemic encephalopathy.

Content

Coroner's Matters of Concern:

1. The Inquest was held one year after Bethan Naomi Harris's death. During the course of the oral evidence it emerged that several, in my mind important, learning issues had not been addressed.
2. There were issues relating to handover of patients to midwives and at the time of Inquest there had been no further specific training in relation to handover. Indeed it was stated that the process in place at the time of Bethan's delivery still pertained without alteration. This represented a risk to patients.
3. At the time of Inquest a team debrief, which I consider to be a source of learning to reduce the risk of serious incident in future was still outstanding.
4. There was little evidence from the oral evidence given that any effective reflection, reflective discussions or learning had taken place subsequent to Bethan's birth and then death. I consider it important that organisations seek to ensure individual and collective reflection to seek to avoid repetition. The evidence for this, one year on, was lacking. 

St George's University Hospitals response.