Eddie Coffey
15 Dec 2020 · Coroner Jonathan Stevens · Hertfordshire
The coroner's concerns
1. inability to determine cause of death
“The Serious Incident Report prepared on behalf of East and North Hertfordshire NHS Trust concluded that the Investigation was unable to determine the factors that were directly responsible for the death of baby [the deceased]. This conclusion was directly contradicted by evidence at the inquest.”
2. gross failure in fetal heart rate monitoring
“Evidence was given at the inquest by a Consultant [name redacted] from Lister Hospital that there was a gross failure in the basic medical care provided in the monitoring and management of the foetal heart rate during the labour, and that but for that failure [the deceased] might have survived.”
3. gross failure in fetal heart rate monitoring
“Evidence was given at the inquest by an independent Consultant [name redacted] that there was a gross failure in the basic medical care provided in the monitoring and management of the foetal heart rate during the labour, and that but for that failure [the deceased] would more than likely have survived.”
4. uncertainty of future safety
“It was not clear from the inquest that, despite training implemented by the Trust since the death, that the same situation would not arise again.”
5. widespread use of incorrect guidelines
“The Evidence was given at the inquest by an independent Consultant [name redacted] that 100 maternity units in the country are following the wrong guidelines in relation to managing foetal heart rate monitoring in labour.”