Amelia Barbosa

“While I heard evidence that there has been training for Midwives on how to take cord blood, and I was provided with a copy of a poster that was said to have been in use at the Trust for some time, in April 2023, over 2 years after this delivery, the Midwife gave evidence that she and her colleagues were of the opinion that it was appropriate to take a sample from anywhere in the cord, not just in the clamped area. The expert and the Trust's own Head of Midwifery advised that this was not appropriate. It therefore does not appear that the learning has been passed on to all Trust Midwives and there is a risk that in future cases those treating the baby will be falsely reassured by normal cord pH results which may not be accurate.”

“While I read evidence of some training that had been provided in response to HSIB recommendations for further training on auscultation in addition to saturation monitoring and ECG monitoring during resuscitation, the independent expert also recommended training on UVC and IO access. I am also concerned that there does not appear to have been training in relation to the provision of blood transfusions in such cases to ensure that all potential reversible causes are treated before resuscitation stops.”

“The Head of Midwifery who attended the inquest to advise on issues relating to the recommendations was not in a position to provide evidence on the neonatal position and I have been provided with no evidence by the Trust that these issues have been considered. I am concerned that they require further action.”