Alba Pemberton
10 Sept 2018 · Coroner Andrew Walker · London (North)
The coroner's concerns
1. meconium not classified and not leading to CCG equipment use
“The presence of meconium should be classified as meconium, and not graded, and once present should result in the use of CCG equipment”
2. absence of obstetric review for all birthing centre patients
“That every patient at a birthing centre should be the subject of obstetric review”
3. insufficient obstetric involvement in low risk case management
“That obstetricians should be more involved in the management of low risk cases”
4. lack of multidisciplinary team meetings and poor staff collaboration
“There should be MDT meetings with the obstetric staff and midwifery staff and obstetric staff encouraged to work closely together in the management of low risk cases”