FIG response to outcome of Baby Aspyn Hercules Inquest
Following the conclusions given by HM Coroner on 27th February 2025 at the Inquest touching the death of Aspyn Dottie Hercules, The King Edward VII Memorial Hospital (KEMH) wish to extend our sincere condolences to the parents and family of Baby Aspyn and apologises unreservedly to them for the identified failings in this case.
The KEMH notes the findings of the Coroner and would like to update the community on the action it has taken, and intends to take in relation to this tragic and avoidable death.
The KEMH recognises that certain issues identified in its own externally commissioned report were causative factors in the death of Baby Aspyn. In summary, these issues relate to avoidable delays in decision-making and provision of care.
After Baby Aspyn’s death on 22nd October 2023, the KEMH immediately followed its own internal policy to convene a Significant Event Analysis (SEA). A SEA is standard practice in the event of a serious incident such as an unexpected death and is a process for reviewing the care provided in a structured way with input from all those who were involved. The insights provided from the SEA quickly made it apparent that in some respects, the KEMH may have failed to deliver the quality of care expected. For this reason, the Director of Health and Social Services and the Chief Medical Officer decided to commission an urgent independent external review of this case.
This external review took place in March 2024, and was undertaken by an experienced consultant obstetrician and specialist midwife. The findings and opinions of these two experts formed a key part of the evidence during the Inquest.
The external reviewers engaged with Baby Aspyn’s parents whilst undertaking their investigations, and the KEMH also met with her parents to discuss its content once received.
Taking into consideration the conclusions from both the external report and the internal SEA, the KEMH developed a 42-point improvement plan to address the issues identified. HM Coroner was provided with a copy of the action plan and noted the acceptance by the KEMH of its failings and that work was already underway to improve maternity services in the Falkland Islands.
Senior Management at the KEMH having been meeting regularly to monitor progress with its actions plan and have been reporting updates to the Health and Medical Services Committee (HMSC). At this point in time the KEMH assesses that only one point has not been started. 33 points have been completed in their entirety with the remainder being underway. The outstanding action is to undertake engagement with service users, and this is planned to commence later this year at the time of the further external review KEMH is in the process of commissioning.
The KEMH is currently commissioning a full independent review of maternity services and audit of its own action plan, scheduled to occur in October of this year. The terms of reference will include a review of HM Coroner’s findings, progress with the current improvement plan, and to provide any new recommendations to further improve the maternity service and ensure patient safety. Service users and other members of the public will have the opportunity to share their views and experiences and the report will be made publicly available.
These matters are a priority for the KEMH, and we wish to provide an assurance that we are striving to make giving birth in the Falkland Islands as safe as possible in the context of a remote environment. This includes ensuring medical officers or consultant obstetricians are involved antenatally throughout pregnancy as well as during labour and birth, ensuring that health professionals clearly understand who is responsible for care pathways during labour and birth as well as ensuring collective communication with nursing/midwifery, medical and theatre staff when a patient is in labour at the KEMH. The KEMH will communicate a further update on these important matters later in the year prior to the independent review.
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