Owen Richard Widlake · Prevention of Future Deaths report

On 03/06/2016 I commenced an investigation into the death of Owen Richard Widlake. The investigation concluded at the end of the inquest on 17 November 2017 that Owen Widlake died of natural causes as a result of undiagnosed PPHN. It is not possible to say on the balance of probabilities whether Owen would have survived if his significant respiratory distress had been recognised, investigated and treated at the time. The cause of death was found to be 1a) Acute Intraventricular Haemorrhage 1b) Persistent Pulmonary Hypertension of the Newborn and Meconium Aspiration.

Owen Widlake was born on the 30th May 2016 at St Mary's Hospital, Isle of Wight full term and healthy, but had aspirated meconium. He was placed in ambient oxygen and continued to need oxygen at ever increasing levels. The failure of his respiratory function was recognised in part, though the severity was not. Transfer to a tertiary specialist neonatal unit was not sought early enough particularly considering the geographical location at St Mary's. He was diagnosed at a late stage with PPHN and as this was untreated it could not be resolved. He suffered an acute intraventricular haemorrhage which on the balance of probabilities was a result of the PPHN. He died at Southampton General Hospital on the 31st May 2016.

(1a) Staffing levels over the weekend and bank holiday, in particular the use of ANNP and SANNP trained staff to replace junior and registrar level doctors on duty covering NICU.
(1b) The need for a dedicated junior level doctor or registrar to be on duty 24 hours covering NICU, and not a limited 3 / 4 hour shift.
(1c) The need to clarify as to the role an ANNP or SANNP has, whether in a nursing capacity or medical capacity, and how they are perceived by other staff.
2) The observations for children in transition or admitted to NICU are not recorded seamlessly nor are easily viewable whether on a chart or graph.
3) The nursing staff do not appear able to escalate concerns either
i) due to lack of clear care plans and escalation markers
ii) poor training particularly the SANNP and ANNP in the recognition of respiratory distress and PPHN
ii) a lack of empowerment indicating a lack of leadership.
4) The on going training undertaken of nursing staff in relation to PPHN and respiratory distress has been the responsibility of SANNP ████████ and a consultant, with no indication that they have undertaken training themselves.
5) Concern as to staff deciding whether a child in respiratory distress should be NBM or not and what is the guidance on this.
6) The Transfer policy for this Trust and what would be guidance or indicators as to the seeking of tertiary level assistance and transfer, especially when a crisis point may be reached past 10pm.
7) What is the current system in place for handovers between medical staff and nursing staff, whether written or verbal, and what information must be included as part of that handover.