Latest news with #PreventionofFutureDeaths
North Wales Chronicle
27-05-2025
- Health
- North Wales Chronicle
Baby died after ‘gross failures' at Ysbyty Gwynedd in Bangor
Etta-Lili Stockwell-Parry's death, on July 7, 2023, was found to have been contributed to by neglect following an inquest last week. Kate Robertson, senior coroner for North West Wales, has since issued a Prevention of Future Deaths report to Betsi Cadwaladr University Health Board, in which she highlights 'many incidences of learning'. The inquest heard that Etta was born at Ysbyty Gwynedd on July 3 in a 'poor condition', following an assisted birth. She died four days later at Arrowe Park Hospital, Wirral, where she had been transferred. Her cause of her death was recorded as hypoxic ischaemic encephalopathy (brain injury caused when a baby's brain doesn't receive enough oxygen or blood flow, either before, during, or shortly after birth). Ms Robertson said there were 'several opportunities not taken' by those caring for Etta's mother prior to the birth – her pregnancy was described as 'uneventful' until June 21. Static growth had not been identified, so there was no referral to obstetrics. Etta's mother 'ought to have been referred to the labour ward for close monitoring,' Ms Robertson said, but instead was induced. The coroner added: 'She received intermittent monitoring. 'The holistic assessments were not always completed and not entirely complete, the partogram did not note baseline foetal heart rate only as required, the maternal pulse was not always taken and recorded and there was no recognition that Etta's mother's pulse was being recorded as opposed to the foetal heart rate. 'There were several gross failures identified in Etta's mother's care which resulted in opportunities not taken to deliver Etta before she became distressed.' While the health board undertook its own internal investigations into Etta's mother's care, Ms Robertson said its neonatal investigation was 'not thorough' and 'based on records alone'. She noted that these records were 'often incomplete or included retrospective entries', and that statements from 'crucial individuals' were not obtained. Some witnesses had only received and read the report several weeks prior to the inquest, meanwhile. Ms Robertson added: 'Having issued reports to the health board regarding quality of investigation previously, this concern remains. 'Specifically, I have concerns that the neonatal element of the investigation was not thorough enough, such that without this, genuine learning and change will not and cannot occur. 'Even where learning has been shared, I am concerned that this is not contextualised sufficiently. 'I am also concerned that staff not involved in the incident will not learn fully enough from events where there is inadequate sharing of learning from an incident.' The health board is duty-bound to respond to Ms Robertson's report by July 16, detailing action taken or planned to be taken. Angela Wood, executive director of nursing and midwifery services at Betsi Cadwaladr University Health Board, said: 'We would like to extend our deepest sympathies and heartfelt condolences to Mr and Mrs Stockwell-Parry following the tragic death of baby Etta. 'We recognise the profound impact this has had on the family, and we are truly sorry for the pain and loss they have endured. 'Since this tragic event in July 2023, we have carried out a thorough review of the care provided and taken significant steps to ensure that the issues identified have been addressed. 'We are committed to learning from this and have implemented a range of measures to strengthen our training and clinical oversight to ensure the safest possible care for mothers and babies. 'We want to reassure expectant mothers and families in our care that this was an isolated incident. 'Providing safe, compassionate care is our highest priority, and we remain committed to upholding the highest standards of care across our maternity services.'
Wales Online
24-05-2025
- Health
- Wales Online
'Gross failures' and 'neglect' played part in death of newborn baby
'Gross failures' and 'neglect' played part in death of newborn baby A Prevention of Future Deaths (PFD) report has been issued to Betsi Cadwaladr University Health Board after the death of a newborn baby girl (Image: PA ) The death of a newborn baby girl was in part caused by "gross failures" in medical care and "neglect". A coroner said she was so concerned about the circumstances surrounding the death of Etta-Lili Stockwell-Parry in 2023 that she issued a Prevention of Future Deaths (PFD) report to the Betsi Cadwaladr University Health Board (BCUHB). Her mother Laura Stockwell-Parry was induced and Etta-Lili was born "in poor condition" on July 3, 2023,at Ysbyty Gwynedd, Bangor having suffered oxygen starvation, according to a pathologist. She was taken to Arrowe Park Hospital on the Wirral but died there four days later on July 7. At a two day inquest in Cernarfon Kate Robertson, senior coroner for north west Wales, found that neglect was a contributory factor in the little baby's death. Staff had failed to notice problems early enough and a subsequent investigation wasn't thorough enough, the coroner said. Neither a community midwife before the birth, nor maternity unit staff at Ysbyty Gwynedd noticed the baby had stopped growing at about 40 weeks, the hearing was told. Sign up for our free daily briefing on the biggest issues facing the nation sign up to the Wales Matters newsletter here. (Image: Daily Post Wales ) Article continues below North Wales Live reported that the health board said said "significant steps" had been taken to address the failures in this case, which it said was an "isolated incident". Mrs Robertson found cause of death was hypoxic ischaemic encephalopathy. She recorded a narrative conclusion at this week's inquest. In a Prevention of Futue Deaths report statement, issued after the inquest the coroner said there were "several gross failures" identified in Etta's mother's care. These failures resulted in opportunities not taken to deliver Etta before she became distressed. There were "many incidences of learning" relating to Etta's resuscitation at Ysbyty Gwynedd, she added. Mrs Robertson found: "There were several opportunities not taken by those caring for Etta's mother. "There were opportunities to identify concerns with Etta through her mother on the midwifery led unit on 2 July 2023 including properly conducting holistic assessments, properly completing partogram and manual palpation of maternal pulse which would also likely have resulted in earlier detection of distress and successful delivery. Etta's death was contributed to by neglect." The coroner also found that Mrs Stockwell-Parry ought to have been referred to the labour ward for close monitoring, but instead, she was induced and received only intermittent monitoring. Her pulse was not always taken and recorded and there was no recognition that Etta Lili's mother's pulse was being recorded as opposed to the fetal heart rate. Mrs Robertson also found the neonatal investigation was not thorough. The investigator neither obtained nor requested statements from the doctors directly involved in Etta's resuscitation, nor did they meet them to understand what had occurred. Mrs Robertson said she is concerned that staff not involved in the incident will not learn enough from events where there is inadequate sharing of learning from an incident. She issued the Prevention of Future Deaths report about her concerns. BCUHB has 56 days to respond with a timetable of how it will act on points raised. Angela Wood, Executive Director of Nursing and Midwifery Services at Betsi Cadwaladr University Health Board, said "significant steps" have been taken to address the issues in this "isolated incident". She said: "We would like to extend our deepest sympathies and heartfelt condolences to Mr and Mrs Stockwell-Parry following the tragic death of baby Etta. We recognise the profound impact this has had on the family, and we are truly sorry for the pain and loss they have endured. "Since this tragic event in July 2023, we have carried out a thorough review of the care provided and taken significant steps to ensure that the issues identified have been addressed. We are committed to learning from this and have implemented a range of measures to strengthen our training and clinical oversight to ensure the safest possible care for mothers and babies." Article continues below She added: "We want to reassure expectant mothers and families in our care that this was an isolated incident. Providing safe, compassionate care is our highest priority, and we remain committed to upholding the highest standards of care across our maternity services."
North Wales Live
23-05-2025
- Health
- North Wales Live
'Gross failures' in medical care and 'neglect' played part in tragic death of baby girl
"Gross failures" in medical care and "neglect" played a part in the death of a newborn baby girl. A coroner was so concerned about the circumstances surrounding the death of little Etta-Lili Stockwell-Parry in 2023 that she issued a Prevention of Future Deaths (PFD) report to the Betsi Cadwaladr University Health Board (BCUHB). Laura Stockwell-Parry was induced and baby Etta-Lili was born "in poor condition" on July 3, 2023,at Ysbyty Gwynedd, Bangor having suffered oxygen starvation, according to a pathologist. She was transferred to Arrowe Park Hospital on the Wirral but died there four days later on July 7. Kate Robertson, senior coroner for north west Wales, who held a two-day inquest in Caernarfon into Etta-Lili's death this week, found neglect was a contributory factor. Mrs Robertson said staff had failed to notice problems early enough and a subsequent investigation wasn't thorough enough. Neither a community midwife before the birth, nor maternity unit staff at Ysbyty Gwynedd noticed the baby had stopped growing at about 40 weeks. Get all the latest Gwynedd news by signing up to our newsletter - sent every Tuesday The health board described the failures as an "isolated incident". Mrs Robertson found the cause of death was hypoxic ischaemic encephalopathy. She recorded a narrative conclusion at this week's inquest. In the PFD report statement, issued yesterday, she said there were "several gross failures" identified in Etta's mother's care which resulted in opportunities not taken to deliver Etta before she became distressed. There were "many incidences of learning" from a neonatal perspective relating to Etta's resuscitation at Ysbyty Gwynedd, she added. Mrs Robertson found: "There were several opportunities not taken by those caring for Etta's escalate from a midwife to a registrar due to static growth which would have led to induction of labour and likely safe delivery of Etta. "There were opportunities to identify concerns with Etta through her mother on the midwifery led unit on 2 July 2023 including properly conducting holistic assessments, properly completing partogram and manual palpation of maternal pulse which would also likely have resulted in earlier detection of distress and successful delivery. Etta's death was contributed to by neglect." She found Mrs Stockwell-Parry ought to have been referred to the labour ward for close monitoring. Instead, she was induced. She received intermittent monitoring. Her pulse was not always taken and recorded and there was no recognition that Etta Lili's mother's pulse was being recorded as opposed to the fetal heart rate. Mrs Robertson also found the neonatal investigation was not thorough. The investigator did not obtain or request statements from doctors directly involved in Etta's resuscitation, nor did they meet them to understand what had occurred. Mrs Robertson said she is concerned that staff not involved in the incident will not learn fully enough from events where there is inadequate sharing of learning from an incident. She issued the Prevention of Future Deaths report about her concerns. BCUHB has 56 days to respond with a timetable of how it will act on the points raised. Angela Wood, Executive Director of Nursing and Midwifery Services at Betsi Cadwaladr University Health Board, said it has taken "significant steps" to address the issues in this "isolated incident". She said: 'We would like to extend our deepest sympathies and heartfelt condolences to Mr and Mrs Stockwell-Parry following the tragic death of baby Etta. We recognise the profound impact this has had on the family, and we are truly sorry for the pain and loss they have endured. 'Since this tragic event in July 2023, we have carried out a thorough review of the care provided and taken significant steps to ensure that the issues identified have been addressed. We are committed to learning from this and have implemented a range of measures to strengthen our training and clinical oversight to ensure the safest possible care for mothers and babies." She added: 'We want to reassure expectant mothers and families in our care that this was an isolated incident. Providing safe, compassionate care is our highest priority, and we remain committed to upholding the highest standards of care across our maternity services.'
Yahoo
15-05-2025
- Health
- Yahoo
Rise in deaths in state detention an ‘escalating crisis behind closed doors'
The number of deaths in state detention reported to coroners in England and Wales for investigation increased significantly last year, new figures show. Some 546 deaths in state detention were reported to coroners in 2024 – an 11% increase on 492 the previous year, according to Ministry of Justice (MoJ) data. The MoJ said this was driven by a 16% rise in deaths in prison custody. One charity boss said the figures were evidence of an 'escalating crisis behind closed doors'. A total of 359 deaths in prison custody were reported to coroners last year – up from 309 the year before. There were also 16 deaths in police custody, four deaths in immigration removal centres and 151 deaths of people subject to detention under the Mental Health Act. All deaths in England and Wales must be registered with the Registrar of Births and Deaths, and can also be reported to coroners who must investigate if there is reason to believe the cause of death is unknown or the death was violent, unnatural, or occurred in custody or other state detention. Nearly a third (31%) of all deaths registered across the two countries were reported to coroners in 2024. Ministry of Justice (MoJ) figures show a total of 174,878 deaths were reported to coroners for investigation in 2024 – a 10% decrease on the previous year, and the lowest figure since records began in 1995. Deaths in state detention are systematically investigated, including by other bodies such as the police and ombudsmen, before being subject to a coroner's inquest. Deborah Coles, director of the charity Inquest, said the rise in prison deaths is 'shocking', and called for more focus on coroners' reports on preventable deaths in detention. She said: 'These statistics are a reminder of an ongoing and escalating crisis behind the closed doors of our prisons and mental health hospitals.' The MoJ said the introduction of a new examination system, meaning every death is subject either to a medical examiner's scrutiny or to a coroner's investigation, may have affected the number of deaths reported to coroners. The new system was rolled out to ensure only those deaths which require investigation are referred to coroners, in order to reduce inquest backlogs and delays. Ms Coles warned the increase in prison deaths 'goes hand in hand' with the rise in the number of Prevention of Future Deaths (PFD) reports issued by coroners in 2024, which are issued when there is a concern action should be taken to reduce or prevent the risk of other deaths occurring in the future. The MoJ figures show 713 PFD reports were issued in England and Wales in 2024 – a 25% jump from 569 the previous year and up from 404 in 2022. Ms Coles added: 'Without a national oversight mechanism to ensure these reports are acted on, preventable deaths will persist. 'We urgently need a system that tracks these recommendations, ensures accountability, and protects lives.' An MoJ spokesperson person said: 'All deaths in custody are investigated by the Prisons and Probation Ombudsman and are subject to a coroner's inquest. 'We will always consider these independent investigations carefully and taken action any concerns.'
Business Mayor
13-05-2025
- Health
- Business Mayor
Charity boss slams 'reprehensible' health trusts
Stuart Woodward BBC News, Essex Reporting from Lampard Inquiry Jamie Niblock/BBC Deborah Coles said the behaviour of some NHS trusts at inquests was 'reprehensible' Health trusts have repeatedly tried to prevent coroners from issuing Prevention of Future Death reports in order to protect their reputations, an inquiry has heard. Deborah Coles, director of the charity Inquest, told the BBC the 'reprehensible' behaviour was a pattern 'played out across the country' but was 'exemplified' in Essex. She gave evidence at the Lampard Inquiry, which is looking into the deaths of more than 2,000 people being treated by NHS mental health services in Essex between 2000 and 2023. Essex Partnership University NHS Foundation Trust (EPUT) has apologised to those affected. 'Angry and frustrated' In her evidence to the inquiry, Ms Coles said the 'lack of candour' on the part of mental health trusts in Essex was the reason a statutory public inquiry needed to be held. 'It's difficult to say how traumatising that is for families when they sit in at an inquest… and then see legal representatives try and effectively stop a coroner from making a Prevention of Future Deaths report, which is ultimately about trying to safeguard lives in the future – and I find that reprehensible,' she said. 'We are talking here about trying to protect lives and also remember those who've died where those deaths were preventable.' Stuart Woodward/BBC The Lampard Inquiry is hearing evidence at Arundel House in London across several sessions in 2025 and 2026 Speaking to the BBC after giving evidence, Ms Coles said NHS trusts were more concerned about reputational damage than learning lessons. 'This goes to the heart of what I was talking about [in the inquiry]… the fact that trusts are more concerned with protecting their reputations than acknowledging the failings in their systems and processes and trying to do something meaningful about it,' she said. Ms Coles added that she was also angry and frustrated at a lack of political will from successive governments 'to ensure the change that is needed… to try and stop the appalling culture of defensiveness that we see from NHS trusts, exemplified by Essex'. 'NHS trusts try and argue with coroners that they've already implemented changes and that a report is not necessary,' she said, adding that it undermined potential for local and national learning. 'We need to be able to ensure that we're not talking about cut-and-paste action plans, but we can demonstrate that action has been taken and that recommendations are implemented.' A Department of Health and Social Care spokesperson said: 'It's crucial that every person affected by this ordeal has a right to tell their story. 'The inquiry has heard testimonies from many families, and we are confident that the inquiry will provide a valuable channel for them to have their voices heard.' PA Media Bereaved families were praised by Ms Coles for their 'incredible strength, courage and determination' The public inquiry is England's first into mental health deaths, with evidence being heard in London after sessions in September and November. Evidence will continue to be heard throughout 2025 and 2026, with Baroness Lampard's report due to be issued in 2027. EPUT chief executive Paul Scott has apologised for deaths under his trust's care. He said: 'As the inquiry progresses, there will be many accounts of people who were much loved and missed over the past 24 years and I want to say how sorry I am for their loss.' READ SOURCE
