Caspian Thorn

1. 1. lack of communication between midwives and social workers

   “lack of communication between the teams of midwives and social worker”

2. 2. lack of clarity in supporting vulnerable families

   “lack of clarity about how to effectively support and manage the nN J situation”

3. 3. undocumented triage calls

   “two undocumented calls to triage on the morning of 24 September 2018”

4. 4. undocumented non‑compliant decision making

   “Decision making that was not in accordance with trust guidance on 10'* September was not clearly documented”

5. 5. delayed review of pathological CTG

   “1% CTG on 24'" September was a pathological CTG from the very early stages but was not reviewed until half an hour had elapsed”

6. 6. missed early sepsis signs in neonate

   “Early signs of sepsis were not identified by the consultant neonatologist because it was thought the observations reflected a move to warming from cooling”

No published response was found on judiciary.uk.