Charlie Mark Jermyn · Prevention of Future Deaths report

Charlie Mark Jermyn died on 10th May 2015. An investigation was opened on 22nd May 2015 and an inquest was opened on 23rd September 2015. A three day hearing was held between the 9th – 11th February 2016 at Truro Municipal Buildings, Truro.

The cause of death was recorded as 1a Massive Hypoxic-Ischaemic Brain damage 1b Pneumonia caused by Beta Haemolytic Streptococcus Group A Infection. The conclusion of the inquest was “Charlie Mark Jermyn died from natural causes contributed by a sequence of failures in the health care system during the first 24 hours of life”.

Charlie Jermyn was born at full term in the bathroom at his home address, ████████ on 9th May 2015 with a birth weight of 2.820 Kg (5th centile). The birth was attended by his father and no health professionals, as the labour progressed rapidly. A midwife assisted with the delivery of the placenta. The midwife reviewed mother and baby between around 5.30 – 9.30 am and found them both healthy and breast feeding was established. They were reviewed by another mid-wife between 18.00 – 19.30 pm where they had been an alteration in Charlie’s behaviour. He was sleepy, there was difficulty feeding and possible respiratory distress (grunting), which are all possible signs of sepsis. At around 22.37 pm the parents contacted the Maternity Helpline and were advised further on the feeding difficulties and the grunting was not addressed. A further midwife attended at 10.00 am on the 10th May and during the routine visit Charlie stopped breathing and was transferred by ambulance to the Royal Cornwall Hospital, Treliske, Truro. Despite resuscitation attempts he died at 10.52 am as a result of a Streptococcus Group A Infection. If signs for sepsis had been recognised on the 9th May, he would have been transferred to hospital earlier and provided with the appropriate treatment to prevent death.

1. The Delay of over 5 hours, in full assessment of ████████ labour progress in the Day Assessment Unit at Royal Cornwall Hospital on the 8th/9th May 2015 was unacceptable (systemic failing).

2. Routine physiological observations of mother and baby were not undertaken and recorded by the Community Midwives. This practice is not in line with national practice. The accurate temperature, heart rate and other appropriate observations/ recording should be routine and formally recorded with stethoscope and thermometer etc (not just visual and touch). NEWS should be completed on all babies.

3. The Royal Cornwall Hospital Trust core midwifery paperwork does not meet best practice or NICE guidelines and does not prompt midwives to undertake routine physiological assessments.

4. All Community Midwives should be provided with standard equipment to include, ear thermometers, stethoscopes, blood sugar testing and SATS monitors and these should be used as routine practice to make routine observations on mother and baby.

5. There was a recommendation by the Midwife Consultant that centile charts for each baby should be available in all hand held maternity records to assist midwives identify babies who are potentially at risk.

6. The Expert Midwife advised that the use of a single birth weight in the Trusts hypoglycaemic guidance (at risk at 2.5 kg) was not best practice and suggested the use of three weights: pre term, term, and late weight.

7. The telephone Maternity Helpline was inappropriately triaged by unregistered inappropriately trained and qualified staff, who were unable to identify obvious and significant sepsis markers indicating the seriousness of the deterioration in Charlie’s health. No structured note taking or recording of the call was made for future referral. Nor was the call/caller recorded. Helpline triage is a complex task and should only be undertaken after specialist training by an appropriately qualified person and the outcome of the conversations should be recorded formally in line with best practice.

8. The red flag signs for sepsis (in this case sleepy, possible respiratory distress (grunting) and difficulty in feeding) were overlooked resulting in a fatal delay in referral to specialist hospital support/treatment. Identification of sepsis in new born babies is difficult and the staff and Trust should have had in place a systemic, rigorous and regular training in this area. The Trust's own clinical guidelines for the Prevention, Diagnosis and Treatment of Early Onset Neonatal Bacterial Infection, were not known to the midwives at the inquest. The Expert Midwife gave the opinion that the RCHT Trust guidelines were not consistent with the NICE guidance or best practice on this matter (page 14). In particular it was noted that capillary re-fill time should be undertaken and recorded in cases of suspected sepsis.

9. The Expert Midwife noted that RCHT SI and SOM were not appropriate and been identified in the most recent LSA report on the Trust.