Prevention of Future Deaths Report – Brandon-Robert Collins-Hayward

Summary

This is the coroners report into the death of Brandon-Robert, who was born on 29 May 2020, and died of E. coli sepsis a week later.

Content

The Coroner notes that, although he was assessed at home by the midwifery team at aged 5 days, no basic observation assessments were taken, such as temperature, heart rate and respiration rate, from the deceased or his mother to confirm their wellbeing. There is no national guidance for such checks, however, University Hospital Dorset NHS Foundation Trust (UHD) have since changed their local policies to embed better safety nets. The local policy now provides guidance that at each visit up to day 10 post birth, a full set of baby and maternal observations are to be taken.

The Coroner also noted that although Brandon-Robert's mother was admitted to hospital the day before his death with an infection and a high risk of developing sepsis, he was not also medically assessed. Again, there is no guidance nationally for babies to be medically assessed when a mother is admitted to hospital. UHD have now put in place a local policy titled which provides guidance to be applied when a women presents at the hospital within 28 days following the birth. This advises that when a mother is admitted to a UHD Hospital, the baby should be medically reviewed either in hospital, or at home by the midwifery team, to ensure the medical wellbeing of the baby.

In the report, the Coroner summarises her concerns as per below:

1. I am concerned that due to the lack of national guidance regarding close monitoring of mothers and babies following discharge after birth, and the fact that there is no national guidance for a medical assessment of a baby when the mother is admitted to hospital with potential sepsis, there could be a death in the future.
2. I would therefore request there is a review of the guidance in place for post-natal care following the discharge from hospital in the immediate time following the birth, namely 10 days and a review of the national guidance in place when a mother is admitted to hospital within 28 days of birth, especially when diagnosed with infection and at high risk of developing sepsis.

Follow the link below for the full report and responses to date.