Ethan Johnson
29 Sept 2015 · Coroner Thomas Osborne · Milton Keynes
The coroner's concerns
1. junior midwife left alone with abnormal CTG
“That the most junior member of staff (midwife) was left to look after even though the CTG trace was deemed abnormal. The midwife felt unsupported.”
2. lack of leadership to require doctor review
“Two further members of staff reviewed the CTG trace and yet it appears that no one was in a position of leadership to require a doctor to attend and review the trace”
3. consultant delayed without leadership insistence
“When the consultant on call was requested to attend he indicated that he would do so later. No one on the unit had the leadership role to insist upon his attendance”
4. staff misunderstanding of labour ward management
“There appeared to be a lack of understanding by members of staff as to labour ward management because of the lack of effective leadership”
5. hierarchical escalation of care
“There still appears to be a hierarchical approach to escalation of care within the unit”