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Coroner's Matter of Concerns: Evidence was heard that there was a delay in Mrs Brind being transferred from the ambulance to the Emergency Department of the Queen Elizabeth Hospital as there was no space in the hospital As delays are a reoccurring problem, checks are made by paramedics and Hospital clinicians on patients while they wait in ambulances for transfer into the hospital to assist in prioritising the need for transfer. In the case of Mrs Brind, physiological observations were not undertaken regularly in accordance with East of England Ambulance Service Trust (EEAST) Guidance and when they were taken, her high NEWS2 score was not escalated to the Hospital Ambulance Navigator who assesses priority for beds in the hospital. Further Mrs Brind was not assessed by a senior doctor from the Hospital within an hour, in accordance with Hospital protocol Coroner was satisfied that steps have been taken by both EEAST and the Hospital in respect of these matters and do not make a report in respect of either of these matters Evidence was heard that there are regularly too many patients in the Emergency Department and so ambulances cannot safely transfer patients into the Emergency Department. The EEAST is working with the Hospital (along with other hospitals in the area) to find ways to deal with this problem and methods are in place to try to alleviate the consequences of these delays. However, it was heard that this is a much wider and more complex problem, in that the Hospital is unable to discharge patients who are medically fit to be discharged and they remain occupying much needed beds. This in turn means patients cannot be moved from the Emergency Department into the hospital wards, and patients remain waiting in ambulances. This in turn causes delays in ambulances being returned to normal duty and being able to attend to emergencies in the community. Evidence was heard that at the time of Mrs Brind’s death, approximately 7 ambulances were waiting to transfer patients into the Emergency Department, Queen Elizabeth Hospital. At the time of the inquest, this had risen to 17 ambulances commonly waiting to transfer patients from the ambulance into the Emergency Department. Further at the time of the inquest there were approximately 140 beds at the Queen Elizabeth Hospital occupied by patients who were medically fit to be discharged, but beds could not be found in the community.

The coroner raised the following matters of concern: Jeesal Cawston Park (JCP) Jeesal Akman Care Corporation was the care provider for JCP and closed in 2021. However, Jeesal Holdings Ltd, Jeesal Residential Care Services Ltd (JRCSL) and possibly other linked companies with the same directors, continue to provide residential care to persons with mental health illness, learning disabilities, complex needs and physical disability. The concerns raised at the inquest could apply to residential care offered by these companies and unless such concerns are addressed there is a risk that future deaths may occur. It is not known if the directors of these companies are directors of other companies providing care for persons with learning and other disabilities. CCTV was shown at the inquest which revealed Ben King had been assaulted in the hours prior to his death and also that 1 to 1 observation was not carried out in accordance with the Observations Policy. CCTV is a reliable means of ensuring that staff comply with Policies and residents are treated with dignity. CCTV is not available in many if not all of the residential homes owned by JHL and JRCSL. Basic dietary advice and guidance provided was not followed by staff. The use of the Dietician in training of staff was reduced in 2017 from one day’s training to an hour’s power point presentation. Important records were not completed by staff, eg Food intake, Exercise, Weight and vital observations. Evidence was heard that exercise was not regularly offered to Ben King and when the Sports Instructor was absent for lengthy periods of time, there was no replacement Multi-Disciplinary Team (MDT) Meetings were not held every 4 to 6 weeks as required. At MDT meetings which did take place, out of date weight measurements were recorded and relied upon for Ben. His increasing weight gain was not discussed at these meetings and weight loss was not set as a desirable or essential goal. JCP used the Pandora software system, (company Directors for Pandora are the same as for JHL and JRCSL) which is still used at the residential homes owned by JHL and JRCSL. Concerns were raised at the inquest in respect of this software system in that not all policies and documents were available to staff on the IPads provided, some of the documents were unwieldy and difficult to read (for example, Personal Healthcare Plan), the Dietician recommended use of paper records in respect of Food and Fluid intake as these would be more accessible to staff and encourage the documents to be completed or in the alternative providing for the records on Ipads to be more easy to access and complete. The internal investigation carried out following Mr Ben King’s death did not capture the concerns raised at inquest. Evidence was heard that no substantive changes have been made at the residential homes owned by JHL and JRCSL following the death of Ben King and the closure of JCP to deal with these concerns. Norfolk and Norwich University Hospital (NNUH) Guidance was sought by Emergency Department (ED) when Ben King attended on 10 July 2020 from a Respiratory Consultant, who was not made aware that Ben King had attended some 6 hours earlier with the same symptoms. The Respiratory on call consultant was not contacted when Mr King returned to NNUH two days later on the 12 July 2020 with the same symptoms. At the time of Ben King’s attendance at NNUH, Ben King was under the Respiratory Team and had been seen a few days earlier, on 3 July 2020. The Respiratory Team was not made aware of Ben King’s attendances at ED on 9, 10 or 12 July 2020 with respiratory problems. Advice given on discharge appears to be unclear and contradictory. The expert Respiratory Consultant referred to the advice as being “inadequate, unclear and inaccurate” On the Discharge Form provided on 9 July 2020 it is noted “Plan – home as Ben is back to normal, self, red flags and safety netting covered, to return in the event of any difficulty.” On discharge from ED on 10 July 2020 (second occasion) the hospital record states that Ben King is to return home, encouraged to lose weight, fluids are to be encouraged and “with no need to monitor his sats unless clinically unwell with sats in 60s%”. Not all of this information was included in the Discharge Form on 10 July 2020: The Discharge Form provided under “Other” - “seen by respiratory team, they are happy to send him home, they have clerked their advice on the paper. CPAP and O2” On 12 July 2020 the Discharge Plan provided “Home”. The advice from the Respiratory Consultant seen on 3 July 2020 was for CPAP to stop. Evidence was heard from the Care staff at JCP that they were unclear as to what the plan was with regard to Ben and specifically as to when Ben was to be returned to Hospital. One of the Doctors at JCP contacted the ED, NNUH to try to ascertain what the advice was and was unable to get any substantive response. Email contact was made with the Respiratory Team but no response was received until after Ben King’s death on 28 July 2020. The section headed “Drug History” was not completed on the Discharge Form on Ben King’s attendances on 9 or 12 July 2020. On 10 July, it states “nil significant”. This is despite Ben King being prescribed Promethazine, a sedative medication, affecting the respiratory system. Evidence was heard that not all prescribed medications could be expected to be included in “the small space” provided. That this is a medication where consideration would have been given to a risk/benefit analysis but there was no evidence of any such analysis. Regulation 28 evidence was that not all medication can be listed; only “pertinent” medication. Promethazine would appear to be such a medication. Arterial and venous blood gas samples were taken from Ben King on his attendances on 9 and 10 July 2020, which the Respiratory Consultant said in evidence were incomparable (although this was not the evidence of the Expert Respiratory Consultant). No blood gas samples were taken on the 12 July 2020. A copy of this report was sent to: The Chief Coroner Clinical Commissioning Group Norfolk Safeguarding Adults Review Group Care Quality Commission Department of Health Healthcare Safety Investigation Branch (HSIB) Healthwatch - Norfolk

Yvonne had experienced mental health problems since childhood and was considered originally to have a personality disorder. She was treated by mental health services for many years and had several inpatient admissions, some of which were compulsory. After a period of self-neglect and refused admission, Yvonne was finally detained under the Mental Health Act on 27 January 2020 at Park House Psychiatric unit, Manchester. On admission she was found to be significantly malodorous and have several long-standing serious deep infected ulcers. She had to be transferred to the acute hospital for assessment and treatment where her condition gradually improved and she was given prophylactic venous thromboembolism (VTE) medication until she was medically fit enough to be discharged back to the psychiatric unit on 12 February 2020. When she was readmitted, despite discharge information from the acute hospital stating that she had been treated with VTE prophylaxis and despite Yvonne fulfilling several trigger criteria, a VTE risk assessment was not undertaken in accordance with the detaining authorities’ policy. There was a failure to monitor her condition and make appropriate records or an action and management plan and she did not have further mental capacity assessments. On 19 February 2020 she was again detained and on the morning of 23 February 2020, she had a cardiorespiratory arrest and was resuscitated for a brief period of time before being taken to the emergency department of North Manchester General Hospital. Further attempts at resuscitation proved unsuccessful and she was pronounced dead due to a pulmonary thromboembolism. The Greater Manchester Mental Health NHS Foundation Trust (GMMH) serious incident investigation failed to establish: whether the responsible clinician, junior doctors or nursing staff were aware of the trusts VTE policy and if not, why not. if they were aware of it, why was it not complied with. whether there was an awareness and compliance with the policy Trust wide. It also failed to identify, acknowledge or be aware of the death of a patient in 2016 from a VTE at Park House unit. In their report, the Coroner raised the following matters of concern: There was a lack of appropriate safeguarding review, Senior clinical oversight as well as necessary MDT meetings and actions to be completed. It did not appear that all permanent or locum clinical and nursing staff Trust-wide were aware of the VTE policy and how it should be implemented including initial assessments and reassessments of the risks as well as consequent medical management. There was no regular audit of compliance with the VTE policy. There was no training programme to ensure familiarity and compliance. A copy of the report was sent to the Chief Coroner.

Coroner's Matters of Concerns Evidence given at the inquest revealed that there were seven different organisations involved in Hayley’s care all of whom had different systems for recording their clinical notes. The evidence given at the inquest revealed that each of the organisations were reliant on being copied into correspondence or on specific information being shared by others. The evidence at the inquest revealed that communication between those involved in her short life was inadequate and, as each ran separate clinical records systems, they could not access crucial information which could have made a difference ultimately meaning Hayley may not have died when she did. Evidence was given at the inquest that locally some steps have been taken to try to share key data between acute hospitals but there have been significant hurdles which have impeded the process namely, the different information technology systems used, licensing issues for the software, Data Protection requirements, confidentiality and consent issues as well as training and funding. Hayley died following an out of hospital cardiac arrest on Christmas day 2019. If information been shared between different health care organisations particularly crucial information about Hayley’s CTO it is highly likely she would still be alive today.

Mrs Hazel Fleur Wiltshire was admitted to the Princess Royal University Hospital on 14 January 2021 following a fall at home. Although she had a number of factors indicating a risk of further falls, no risk assessments were completed on three wards and there was no evidence that measures that could mitigate the risk of falls were considered. Mrs Wiltshire's toileting care plan indicated that she was to be assisted with her toileting needs and she had access to a call bell. However, there were lengthy delays in responding to the call bell and on the night of 22 January 2021 she tried to relive herself without assistance which caused her to fall. She died in hospital on 19 February 2021 from pneumonia caused by the fall and by Covid 19 that she acquired in hospital. Coroner's concerns: The matron who gave evidence was not aware of obtaining data on response times from the call bell system and had not introduced any other system to monitor response times. Staffing levels were inadequate due to higher dependency of patients with Covid. I heard that one patient had to soil herself in her hand as no one was available to assist her with her toileting needs. Mrs Wiltshire phoned home on occasion to ask her family to call the ward because they were not responding to her call bell. The family could hear other patients on the ward crying out for help. Although Mrs Wiltshire was at risk of falls, no risk assessments were completed on any of the three wards in which she stayed. This suggests a systemic problem across the hospital that requires remedial action.

Coroner's concerns During the course of the investigation the evidence revealed matters giving rise to concern. If the coroner is inhibited from being in a position to confirm the cause of death of a baby, there is a risk that future deaths will occur unless action is taken. Matters of Concern The placenta, a key organ required for a full paediatric post mortem in an early neonatal death, has been interfered with such that the Paediatric Pathologist, is limited in his conclusion as to the likely cause of death. In some ways the placenta is akin to an organ for the purposes of a paediatric post mortem- Loss of an organ at any post mortem examination, may well undermine the ability of the pathologist to carry out a full and proper examination. Decisions surrounding interference with, or disposal of, the placenta should be made in a careful and considered manner, with thought given to an early discussion with the coroner as would happen if organ donation is being considered. This did not happen in this case. Unfortunately, there have been a number of cases in Nottingham where the death of a baby shortly after the birth was anticipated, but the placenta was disposed of and/or interfered with prior to the death being reported to the coroner. This undermines the coronial investigation resulting in limited findings and therefore limited conclusions at inquest. This will likely lead to a lack of learning from such deaths, and therefore a risk that similar deaths will occur in the future. It may also deprive the parents of significant information when considering whether future pregnancies may be at greater risk with the consequent need for appropriate management and planning. The Nottinghamshire Coronial service has to date worked collaboratively with all local Trusts, but particularly with NUH NHS Trust, to ensure key staff understand the importance of retaining the placenta in an early neonatal death. This has not led to the actions necessary to achieve a full and proper examination of the placenta in repeated paediatric post mortems in this jurisdiction.

Coroner's Matters of Concerns: Concerns were raised in relation to the immediate investigation into a suspected death from anaphylaxis, that the evidence obtained at this time, with the right approach, can be invaluable to preventing deaths, but that to achieve this changes are required. This would need changes in the death investigation process and the wider investigation which would need assistance from the Food Standards Agency (FSA). There needs to be better education both to doctors and to patients in risk groups to prevent future death. In relation to Pathology: The current guidance is 10 years old, the suggestion is for this to be revisited and specifically: If bloods are taken at hospital that they are not destroyed in a suspected case but retained for testing. That an early blood sample is taken after death and stored for late analysis. That the possibility that a death is due to anaphylaxis is raised with the Senior Coroner for the area where the death occurred at the earliest opportunity. That an early blood sample is taken after death. The post mortem examination should be prioritised. At the post mortem examination: that stomach contents are taken and frozen to enable testing and that tissue samples are taken. A standard protocol should be available to ensure appropriate samples are taken at the correct time to assist later investigation. In relation to doctors/patients: To highlight, through public awareness and to the medical profession, that while the majority of food-allergic individuals are at very low risk of fatal reactions, a small subset of food-allergic individuals may be at significantly higher risk. These persons must be given appropriate advice as to the dangers of inadvertent exposure, since there may be no detectable safe level of allergen that can be present in a product for this group. To be aware that avoidance of foods in adults does not improve eczema and may result in more severe allergy to the food avoided particularly to cow’s milk but tolerance can be maintained by continued regular exposure. In relation to the FSA, the UK Health Security Agency and the Department of Health and Social Care: To establish a robust system of capturing and recording cases of anaphylaxis, and specifically, fatal and near-fatal anaphylaxis, to provide an early warning of the risk posed to allergic individual by products with undeclared allergen content. Such a system could involve mandatory reporting of anaphylaxis presenting to hospitals, analogous to the current system used for notifiable diseases (including some food-borne illnesses) whereby registered medical practitioners have a statutory duty to notify the ‘proper officer’ at their local council or local health protection team of suspected cases of certain infectious diseases. An example of such a reporting system for anaphylaxis already exists in the state of Victoria in Australia, and also allows for rapid alerts of serious cases to public health authorities to expedite investigation and evaluate the public health risk. In relation to the FSA, the British Retail Consortium, Food and Drink Federation and British Hospitality: The wording used on food products, and the public’s understanding of these phrases in terms of implying the absence of a particular allergen, can be potentially misleading. Examples include: “free-from” and “vegan”. Foods labelled in this way must be free from that allergen, and there should be a robust system to confirm the absence of the relevant allergen in all ingredients and during production when making such a claim. With respect to those with the most severe food allergies, it may be necessary in the interim to clarify that foods labelled “free-from [X allergen]” may not be safe to consume. In relation to the FSA: A hotline to the FSA to provide guidance in fatal cases due to suspected anaphylaxis, although a mandatory reporting system (suggested above) would address this need. Nationally recognised best practice and technical advice to assist those investigating such cases.

Coroner's concerns 1 It is recognised that M. abscessus poses a risk of death to those who are immunosuppressed. That will be so for many patients at specialist hospitals such as Royal Papworth and more generally for hospital patients. To date, 34 patients at Royal Papworth have contracted M. abscessus from the hospital’s water. Cases continue to be reported, albeit at a declining rate. 2 There is an incomplete understanding of how M. abscessus may enter and/or colonise a hospital water system. 3 Health Technical Memorandum 04-01 Safe Water in Healthcare Premises was published by the Department of Health in 2016. It is concerned with the design, installation, commissioning and operation of hospital water systems. This guidance requires urgent review and amendment, whether by way of an Addendum or otherwise because: a. It is a key document for hospital estate managers and Water Safety Groups; b. It purports to provide comprehensive guidance on waterborne bacteria; c. However, it provides no relevant guidance in relation to mycobacteria and none in relation to M. abscessus. It provides no guidance on the identification and control of M. abscessus. It does not require routine testing for mycobacteria, including M. abscessus or provide guidance on acceptable levels (if any). Compliance with the guidance does not identify or guard against the risk from M. abscessus; d. It provides no guidance on any additional measures that may be required in respect of “augmented care” patients, including those who are immunosuppressed; e. It is not in any event consistent with British Standard BS 8580-2:2022 on Water Safety. 4 There is evidence that the risk from M. abscessus is especially acute for new hospitals. Consideration needs to be given to whether special or additional measures are required in respect of the design, installation, commissioning and operation of hospital water system in new hospitals.

Coroner's concerns and recommendations Concern 1 X was recruited as a locum registrar by the Hospital Trust without there appearing to have been any assessment of his skills and abilities or any supervision of him at the hospital. This was not an emergency appointment after, for example, a doctor calling in sick at the last minute. X gave evidence that the recruitment, assessment and supervision of locums is a national problem and that there is a need for a review on a national level. This raises concerns that there may be a risk to other lives both at this trust and at other trusts in the future. Recommendation 1 NHS England and the Royal College of Obstetricians and Gynaecologists consider a review at a national level into the recruitment, assessment and supervision of locum on obstetric and gynaecology wards together with the publication, if appropriate, of new guidelines. Particular emphasis should be 9 considered upon delineating the permitted scope of locums' activities before they are left responsible for out of hours care of women in labour. Concern 2 The current policy of the East Kent Trust states that it is the responsibility of the healthcare professional who will be supervising the locum to assure themselves of his/her competence. This did not happen in this case. There is at present no requirement for a locum to be assessed on a day shift by a consultant before being left in charge overnight. There is no clear direction that it is the responsibility of the assessing consultant to satisfy themselves of the locum's experience and capability. One specialist from outside the East Kent Trust, X, also stated that it would assist the assessing consultants to be able to see not only the locum's CV but also their references and any training records available. Recommendation 2 The East Kent Trust should consider taking action to ensure that there is a dedicated consultant responsible for reviewing the CVs and references of prospective new locums before they are appointed or employed. A record should be kept of the consultant concerned together with a copy of the consultant's written opinion. The East Kent Trust should also consider making the locum's CV, references and training records (where there are any) routinely available to all consultants with whom the locum will work. Wherever possible a locum should be assessed by a consultant upon a day shift before being left in charge overnight. It is also recommended that the East Kent Trust 10 should consider making it clear that it is the supervising consultant who is at all times responsible for ensuring that the locum working under their supervision is both competent and experienced for the role. Concern 3 X had worked two night time shifts at the QEQM before the night of Harry's birth. The extent to which there was any feedback from the consultants on call those two nights to X is unclear. She, erroneously, believed the East Kent Trust had employed X. There is no record of any written feedback. From the evidence of the medical director of the East Kent Trust it appears that the current locum recruitment policy is not being checked or audited. There is a potential for further risks to life arising from these shortfalls. Recommendation 3 Pending any possible review by NHS England and any new guidelines upon the assessment and recruitment of locum doctors it is recommended that the East Kent Trust consider taking action to ensure that consultants who have supervised a locum whether on a day or a night shift should provide written feedback upon the locum's competence and experience to be made available to the relevant HR team at the East Kent Trust and also to any other consultants who may be working with the locum in the future. The East Kent Trust should consider a review of its current procedures as to compliance with policies on the recruitment of new locums, including any new locum recruitment checklist, are being complied with. That review should include 11 consideration of whether there should be a regular audit of compliance. The East Kent Trust should also consider a review of its current procedures relating to the assessment and recruitment of locums to ensure that they meet all current professional guidelines. The East Kent Trust should also review the means by which locums have access to all their policies and procedures including the need for the escalation of care to the consultant, when necessary. There should be consideration of a computer sign in system so that there can be a check that the locum has in fact seen and read the policies. Concern 4 There is a risk to the life of both mothers and babies if there is a lack of clarity as to the processes or the need to take prompt action where it is necessitated in the event of an obstetric concern or emergency developing. Recommendation 4 There should be consideration of a review by the East Kent Trust of the obstetric policies, procedures and protocols which relate to the actions which are mandated by the East Kent Trust in the event of a pathological intrapartum CTG including, specifically, those actions which are required, and the relevant time frame, when the 'expedition of delivery' is called for. Concern 5 There appeared to be from the evidence given at the inquest substantial confusion amongst staff as to when a consultant should be called at night. The East Kent Trust now has some 70 hours a week consultant attendance on the wards. That leaves 14 hours a day when there is no consultant present. Staff, whether doctors, nurses or midwives should know the circumstances in which consultant help should be sought and should not feel inhibited from making their views known. If staff are unaware or unsure of when the consultant should be called that potentially poses a continuing risk to life. Recommendation 5 The East Kent Trust should consider a review the procedures in place to ensure staff understand the circumstances in which consultant attendance is required and, if necessary, deliver specific training upon this issue. Concern 6 The current contracts at the East Kent Trust permit consultants to live up to 30 minutes travel time from the hospital. This poses considerable problems and risks for night time emergencies. Recommendation 6 The East Kent Trust should consider research into any technological solutions which could be found to assist in, or ameliorate, the difficulties of on call consultants living some distance away from the hospital, for instance the use of video link technology or skype connections to the theatres and/or computer terminal readouts from home. Concern 7 The evidence of raised substantial concerns about the quality of training and learning in respect of neonatal resuscitation at the East Kent Trust. His evidence was that it would be desirable for middle grade doctors to attend the ARNI course (the advanced resuscitation of the new born infant). He also recommended that there should be simulated drills in neo natal resuscitation. Recommendation 7 The East Kent Trust should consider a review of the current procedures for all relevant staff to attend regular drills and simulation training events covering neo natal resuscitation. The East Kent Trust should consider whether such training should be mandatory and that attendance at such courses is clearly recorded. Concern 8 Prior to Harry's death both X, a senior member of staff who had the care of Harry at the William Harvey Hospital, accepted that there were no opportunities for cross site working between QEQM and the William Harvey Hospital. Currently two out of eight middle grade doctors have had the opportunity to spend time at the William Harvey, which has a much higher specification neo natal unit. X described the lack of opportunities before Harry's death as ‘at best, very surprising'. Recommendation 8 The East Kent Trust should review the provision of cross site paediatric working so as to ensure that, where possible, within the next two years all middle grade doctors who aren't on the “run through specialist training programme in paediatrics” have spent a period of time at the level 3 William Harvey Hospital. Concern 9 The resuscitation of Harry was eventually carried out by X , the anaesthetist looking after X. His evidence was that leaving his own patient to help the paediatric team was an unusual action to take in the UK although he had often performed such actions in Nepal. Doctors at QEQM indicated that there was an informal policy that if a middle grade paediatrician found themselves in an emergency, they could seek help from their anaesthetic colleagues. It was unclear whether the anaesthetists were aware of this informal policy. This informal policy should be clarified, and guidance given because there is a risk, that in an emergency, it will be overlooked. Recommendation 9 The East Kent Trust should consider a review the circumstances in which anaesthetists are expected to attend and assist neonatal emergencies and to ensure that all relevant members of staff are aware of the policies. Concern 10 There appeared to be considerable confusion among members of staff as to which, if any, guidelines and policies affected them. While two senior members of staff, X (consultant), said that the East Kent Trust has systems in place to ensure knowledge of and compliance with Trust policies neither of them was able to say whether this was effective. Significant issues remain as to the knowledge of staff as to which guidelines govern their behaviour (this was also a finding of the Health and Safety Investigation Board in 2019). Such confusion or lack of knowledge increases the risk of future deaths. Recommendation 10 The East Kent Trust should consider a review of obstetric and paediatric staff's awareness of the governing clinical and operational guidance. The East Kent Trust should also consider keeping a register of when and if every member of staff signed off the relevant guidelines as read and understood. This could take place, for instance, at formal training sessions within the unit. Concern 11 There was a lack of knowledge within the paediatric team of guidelines issued by the Department of Women's Health. The evidence from the East Kent Trust doctors was that the guidelines issued by the department directed to 'all maternity and neonatal staff who may be involved with the immediate care and support of a collapsed neonate' would not have been known to the paediatric team at the relevant time. Even senior clinicians, such as X, were not aware of the relevant guidelines. Recommendation 11 The East Kent Trust should consider taking action to ensure that the current neonatal resuscitation guidelines are brought to the attention of the neonatology and paediatric teams at the QEQM. Guidelines issued by one department, but which are relevant to staff in a different department should be disseminated and understood by those staff. This could take place during senior management meetings, organised cross department training or electronically with the recipient confirming receipt, reading and understanding of the material. Concern 12 The placenta of Harry was not retained. Examination of the placenta will in some circumstances assist in cases of severe foetal distress. The Royal College of Pathologists states that it is 'essential' for the placenta to be sent for examination in cases of severe foetal distress requiring admission to a neo natal unit. Recommendation 12 The East Kent Trust should consider amending its neonatal guidelines to reflect the mandatory nature of the Royal College guidelines to ensure that the placenta is always kept and sent for histology and a record should be kept of each and every such instance. Concern 13 The standard of record keeping on the obstetric unit was substantially sub-standard. The quality of the note taking and records is of considerable importance to new staff taking over responsibility for mother and baby. Without there being clear accurate records there is a risk of further mistakes being made leading, at the worst, to the risk of death. An example of this in Harry's case is that the record of the syntocinin prescribed to X over a long period of time is inconsistent with the evidence of the midwives and the registrar who gave it to her. Recommendation 13 The East Kent Trust should consider an audit of the quality of record keeping and documentation and consider whether further training is required so that staff understand the crucial importance of clear and accurate record keeping. Concern 14 There are no current records kept by consultants who are telephoned at home for advice. In this case there was a dispute about the number of calls made to X and as to the content of these calls. The advice given and the actions taken as a result are important for the preservation of life. Recommendation 14 The East Kent Trust should consider whether consultants should be asked to keep full records of advice given to junior doctors over the telephone and to time and date them. Concern 15 The East Kent Trust should consider a review as to the use or otherwise of a resuscitation pro forma. A pro forma has since Harry's death been adopted by the East Kent Trust which, on the evidence of X, has improved the oversight of neo natal training and governance. It is not clear whether that pro forma is being audited or logged, or what actions are being done to ensure its completion and preservation. Recommendation 15 The East Kent Trust should consider keeping clear records of the use of the pro forma and checking the efficiency of it. The East Kent Trust should also consider whether further training is necessary to ensure the best use of it to prevent further deaths occurring. Concern 16 In order to try to prevent future deaths it is important that there are clear records and statements made when a death occurs so that lessons can be learnt. In this instance many of the statements were very scanty in their content and some were made a long time after the event. In some instances, staff had to make statements from memory without the advantage of seeing the medical notes. Contemporaneous (or as near as possible) notes are also very much in the interests of the staff involved so that they can give clear accounts of their actions and reasons for them if required to do so at a later date. Recommendation 16 Where there has been a serious incident staff should be asked to make statements as soon as possible after the event. They should be provided with the medical records to do so. The statements should then be timed and dated and kept in a secure place by a third party. Concern 17 The child death notification form was incorrectly completed in that Harry's death was recorded as 'expected'. No notification was made to the Coroner. No details were filled in on the notification form giving any detail of the problems leading to Harry's death. As a result, the Child Death Overview Panel would have been unaware of the problems encountered and could not have shared learning to prevent other such deaths occurring. I make no recommendation in respect of the lack of notification to the Coroner as I am aware that the Senior Coroner has already dealt with this. Recommendation 17 The East Kent Trust should consider a review of its policies so that all staff members who fill in Child Death Notification forms are aware of what to enter into the form and of the details required. All such forms should be logged and audited, including those since Harry's death. Concern 18 The MBRRACE form in respect of Harry Richford was inaccurate in a number of important areas. The form is important to provide robust national data to support the delivery of safe, high quality maternal and new born care as well as identifying errors and faults, if any, where there has been a maternal or infant death so that future deaths can be avoided. Recommendation 18 The East Kent Trust should consider a review of all MBRRACE forms filled in since Harry's death were accurately completed and reported. The East Kent Trust should also consider whether it would be advisable to have a second person checking and signing off an MBRRACE form before its submission. Concern 19 Important independent reports do not appear to have been shared within the East Kent Trust's staff, for instance the HSIB report into Harry's death appeared during the inquest to be unknown to a number of the staff. Recommendation 19 The East Kent Trust should consider a review of its policies in respect of the sharing of important investigations amongst all relevant staff so that important learning takes place to prevent any future deaths.

Coroner's concerns Asher was entirely dependent upon a complex package of care as a highly vulnerable ventilator dependent child. Evidence at inquest was that on numerous occasions he was not provided with the prescribed 2:1 care. The care package, despite being described as one of the most complex and most expensive was not appropriately reviewed and there was no mandatory system of quality checks or formal review when there was a significant change in family circumstances. Quarterly reviews were not carried out without explanation. The primary responsibility fell upon the family members, namely Asher’s parents, who were also responsible for other children in the family and employed as teachers. Concerns raised by the parents were not taken for discussion to case conference or professional’s meetings and essentially not followed up at all, leaving the situation in the house dangerous with an ultimately calamitous outcome. There was a lack of scrutiny or reconciliation of Asher’s care package, which could have identified gaps that needed to be addressed. Training for the staff involved was unclear to the court and seemingly not in place or inadequate. A high turnover of staff was cited as one of the reasons, but this should have highlighted a need for increased training and scrutiny. The court was advised that new structures would be in place by July 2022. The production of this report therefore has been delayed to give the opportunity for those systems to be in place and reported to the court.