Daisy McCoy
5 Aug 2025 · Coroner Deborah Stewart · Devon, Plymouth and Torbay
The coroner's concerns
1. lack of training to recognise unusual foetal movements
“A lack of training to recognise unusual foetal movements / compromise and implementation of such training”
2. lack of familiarity with processes and policies by midwives
“A lack of familiarity with the processes and polices by midwives to understand foetal compromise”
3. lack of training and policies on rapid escalation of emergency events
“A lack of training and policies on rapid escalation of emergency events”
4. gap in policy for consultants or midwives to attend in person during understaffing
“A gap in policy to provide for both Consultants and or midwives to attend in person where understaffing may lead to patient safety being compromised outside of the recognised situations where this is required under the FIGO guidelines”
5. lack of understanding and implementation of policies for additional staffing during high acuity or emergency situations
“A lack of understanding and implementation of the polices that additional staffing in times of high acuity or other emergency situations which if left unaddressed may leave patient safety compromised”
6. lack of culture of appropriate professional challenge
“No culture of appropriate professional challenge”