Emmy Russo
19 May 2025 · Coroner Thea Wilson · Essex
The coroner's concerns
1. inadequate patient information on induction risks
“The evidence of the current information given to patients at 40 weeks' pregnant on the decision over whether to accept the offer of an induction from 41 weeks does not reflect NICE guidance on the information needed by patients to make an informed choice on induction. Whilst it provides details of the risks associated with induction, it does not provide information on the risks of continuing with pregnancy beyond 41 weeks.”
2. inconsistent escalation of concerns
“The evidence given at inquest indicated a lack of understanding and/or consistency over when concerns about labouring mothers and/or the CTG trace should be escalated for doctor review. Evidence was given on the measures put in place to address issues with escalation, including”