HM Coroner included BAPM in a recent regulation 28 report. These are used by HM Coroner to reduce the risk of future deaths based on the findings of an index case. The regulation 28 report can be found here.
The narrative conclusion to the inquest includes ‘… that opportunities to identify that [baby] had a pneumothorax were missed. If the pneumothorax had been discovered and treated before a tension pneumothorax and other complications related to Air Leak Syndrome had developed, [the baby] would on the balance of probabilities have survived.’
We wish to share these specific aspects of our response and urge you to consider these for your personal and team based practice.
- With an appropriate local risk analysis, a consultant does not need to be involved in the decision to administer surfactant or perform LISA as long as it is performed by someone with an appropriate level of experience and competence (Consultant Working Patterns – A BAPM Report).
- There are no national guidelines, that mandate the process of performing LISA (Less invasive surfactant administration). BAPM does have a checklist to deliver LISA (Appendix F in the Neonatal Airway Safety Standard). This checklist includes a reminder to consider a pneumothorax as the reason for a baby’s clinical condition. This framework does not include a recommendation to perform a chest x-ray prior to LISA. A pneumothorax may be diagnosed by other means other than an x-ray, including clinical examination, cold light examination or lung ultrasound. The checklist also prompts staff to consider if the consultant is aware (if applicable). This decision would be determined locally, dependent on clinical situation and the experience of the on-site team. A universal policy of seeking consultant approval before undertaking this procedure is not necessary and may delay delivery of LISA.
- Resuscitation of the newly born infant is guided by the Resuscitation Council of the United Kingdom 'Newborn Life support' algorithm. In addition, the Resuscitation Council of the United Kingdom 'Paediatric Advanced Life Support Guideline' includes reversible causes of cardiac arrest (4 H’s and 5 T’s) in its algorithm. These algorithms are produced by a multidisciplinary team of experts and updated on a regular basis. They form the National recommendations to deliver neonatal resuscitation in the United Kingdom.
We include these references for your information:
- Managing the Difficult Airway in the Neonate published October 2020
- Neonatal Airway Safety Standard published in April 2024
- Consultant Working Patterns – A BAPM Report published in November 2023
- Newborn Life support - Resuscitation Council of the United Kingdom
- Paediatric Advanced Life Support Guideline, Resuscitation Council of the United Kingdom
